ATI Templates

Skin changes:

• Hyperpigmentation
• Linea nigra — dark vertical line from umbilicus to pubic area
• Chloasma (mask of pregnancy) on the face
• Striae gravidarum — stretch marks, most pronounced on abdomen and thighs

Breast changes:

• Darkening of the areola
• Enlarged Montgomery's glands
• Increase in size and heaviness
• Increased sensitivity
• Visible vascularization (veins)

Increase in estrogen and progesterone occurring during pregnancy drives both the skin and breast changes.

• Estrogen: stimulates melanocyte activity (hyperpigmentation), increases vascularization, supports breast ductal growth
• Progesterone: supports breast lobule and alveolar development, contributes to glandular tissue enlargement
• Skin stretching from rapid uterine and breast growth produces striae as collagen and elastic fibers tear

Who, when, why, how:

• Acknowledge the client's concerns about pregnancy and encourage sharing of feelings (judgment-free atmosphere)
• Educate that these changes are expected, not pathological
• Discuss timeline for return to prepregnant state after delivery (most fade gradually)
• Recommend sun protection for chloasma — sunscreen, hats, avoiding peak sun
• Reassure about striae — they fade to silvery white over time; no proven prevention via topicals
• Encourage well-fitted supportive bra for breast comfort
• Refer to counseling if body image concerns affect the pregnancy
• Set goals with the client for postpartum self-care and newborn care

Why UTIs are common in pregnancy:

• Renal pelvis & ureteral dilation from progesterone
• Urinary stasis from displaced bladder
• Glycosuria provides bacterial growth medium
• Vaginal flora more alkaline (normally acidic)
• Asymptomatic bacteriuria can progress to pyelonephritis if untreated

Risk: untreated UTI → preterm labor, low birth weight, pyelonephritis (high fever, flank pain, sepsis).

• UTIs are common during pregnancy because of renal changes (smooth muscle relaxation by progesterone, dilated ureters, urinary stasis)
• Vaginal flora become more alkaline during pregnancy, allowing bacterial overgrowth
• The shorter female urethra is in close proximity to anal flora
• Mechanical pressure from gravid uterus on the bladder promotes incomplete emptying

Decrease UTI risk by — When? Why? How?

• How, When: Wipe perineum front to back after voiding (prevents anal flora migration)
• How: Avoid bubble baths (irritate urethra)
• How: Wear cotton underpants; avoid tight pants (allow airflow, reduce moisture)
• How: Drink ≥ 8 glasses of water/day (mechanical flushing)
• How, Why: Urinate before and after intercourse — flushes bacteria present or introduced
• How, Why: Urinate as soon as urge occurs — retention provides bacterial growth medium
• When, Why: Notify provider if urine is foul-smelling, contains blood, or appears cloudy — early treatment prevents pyelonephritis

Why nutrition matters in pregnancy:

• Adequate nutrition supports fetal growth and maternal physiologic adaptations
• Recommended weight gain (single pregnancy): 11.3–15.9 kg (25–35 lb)
• Pace: 1–2 kg in 1st trimester, ~0.5 kg/week in 2nd–3rd
• Insufficient gain → low birth weight, IUGR, preterm birth
• Excessive gain → macrosomia, labor complications, GDM, gestational HTN

Age-related:

• Adolescents may have poor nutritional habits (low vitamins/protein, may not take iron supplements)

Culture / lifestyle:

• Vegetarians may be low in protein, calcium, iron, zinc, vitamin B12
• Excessive weight gain → macrosomia and labor complications

Socioeconomic:

• Inability to purchase or access foods limits adequate nutrition

Dietary complications during pregnancy:

• Nausea and vomiting
• Anemia
• Eating disorders (anorexia, bulimia)
• Pica (craving nonfood substances — dirt, red clay)
• Inability to gain weight

Federal nutrition support:

Other nursing actions:

• Assess client's diet via food journal at each prenatal visit
• Provide education on nutritional benefits to mother and newborn
• Monitor weight gain pattern; identify deviations from target
• Refer to registered dietitian for tailored counseling
• Screen for eating disorders, pica, food insecurity, financial barriers
• Counsel adolescents on age-specific risks and supplement adherence
• Address vegetarian-specific gaps with B12, iron, zinc supplementation guidance

Sensory stimulation strategies:

• Aromatherapy
• Breathing techniques (Lamaze, patterned breathing)
• Imagery
• Music
• Use of focal points
• Subdued lighting

Cutaneous stimulation strategies:

• Therapeutic touch & massage; back rubs
• Effleurage (light circular abdominal stroking)
• Sacral counterpressure (heel of hand or fist on sacral area)
• Heat or cold therapy
• TENS
• Hydrotherapy (whirlpool, shower) — ↑ endorphins
• Acupressure
• Walking, rocking

Cognitive strategies: childbirth education, doulas, hypnosis, biofeedback.

Gate-control theory of pain:

The sensory nerve pathways that pain sensations use to travel to the brain allow only a limited number of sensations to travel at any given time. By sending alternate signals through these pathways (touch, sound, image), pain signals can be blocked from ascending the neurologic pathway, inhibiting the brain's perception and sensation of pain.

Fear-tension-pain cycle: anxiety/fear → ↑ muscle tension → ↑ pain perception → slowed labor. Reducing anxiety is itself analgesic.

Endorphin release: hydrotherapy and movement promote endogenous endorphin release, contributing to natural pain modulation.

Who, when, why, how:

• How: teach methods during prenatal childbirth education classes (3rd trimester ideal)
• When: apply during 1st-stage latent and active phases — when comfort techniques are most effective
• Why: reduce anxiety, fear, tension — major contributors to labor pain; minimize need for pharmacological interventions; improve birth experience
• How: involve partner/doula in providing massage, counterpressure, encouragement
• How: encourage frequent position changes — semi-sitting, squatting, kneeling, supine ONLY with hip wedge
• Why: position changes promote relaxation, fetal descent, and pain relief
• How: assess for hyperventilation (low PCO₂ → numbness, tingling) → breathe into paper bag or oxygen mask
• When: if a client requests pharmacological intervention, offer continued nonpharmacological methods alongside (combined approach optimizes pain management)
• How: document strategies attempted and their effectiveness

Definition: Begins with delivery of the placenta; includes at least the first 2 hr after birth.

Maternal characteristics:

• Maternal stabilization of vital signs
• Achievement of homeostasis
• Lochia: scant to moderate rubra (expected)

Assessment priorities:

• Maternal vital signs
• Fundus (firmness, location)
• Lochia (color, amount, clots)
• Urinary output / bladder distention
• Perineum (episiotomy/laceration repair for erythema)
• Baby-friendly activities

Monitoring schedule:

• BP and pulse every 15 min for first 2 hr
• Temperature at start of recovery; q4h × 8 hr; then q8h
• Fundus and lochia every 15 min for first hour, then per facility protocol

The focus of care in the fourth stage is to maintain uterine tone and prevent hemorrhage.

Why uterine tone matters: The placental site is a large, raw wound. Uterine muscle fibers must contract around the maternal blood vessels supplying that site — this physiologic ligature is the primary mechanism preventing postpartum hemorrhage.

What disrupts uterine tone:

• Bladder distention — pushes the uterus up and to the side, prevents adequate contraction
• Retained placental fragments
• Uterine atony
• General anesthesia agents
• Prolonged labor or rapid labor
• Multifetal pregnancy or hydramnios (overdistention)

Endogenous oxytocin: Skin-to-skin contact and breastfeeding stimulate oxytocin release, which contracts the uterus and supports hemostasis — bonding activities are clinical interventions, not just emotional ones.

Core four (per ALS):

1. Assess vital signs, fundus, and lochia every 15 min for the first 2 hr, then per facility protocol
2. Massage the uterus — and/or administer oxytocics as prescribed to maintain uterine tone and prevent hemorrhage
3. Encourage voiding to prevent bladder distention (a full bladder displaces the uterus and impairs contraction)
4. Promote parental-newborn bonding — facilitates endogenous oxytocin release and supports attachment

Additional interventions:

• Assess episiotomy or laceration repair for erythema, swelling, hematoma
• Apply ice pack to perineum for comfort and edema reduction
• Provide perineal hygiene; clean perineal pad
• Facilitate skin-to-skin contact immediately following birth
• Allow private time; encourage breastfeeding initiation
• After bonding and eating, support a nap or quiet rest period
• Document all assessments and interventions

Anatomic context: Postpartum perineum can be erythematous, edematous, with episiotomy or laceration. Hematomas and hemorrhoids may be present. Healing: initial 2–3 weeks; complete 4–6 months.

Risk factors for perineal injury/poor healing:

• Episiotomy (median or mediolateral)
• Perineal lacerations (1st–4th degree)
• Operative vaginal birth (forceps, vacuum)
• Macrosomia, prolonged 2nd stage
• Maternal diabetes (impaired wound healing)

Assessment using REEDA:

• Redness
• Edema
• Ecchymosis
• Discharge
• Approximation of edges

A bright red trickle of blood from the episiotomy site in the early postpartum period is a normal finding.

Three core principles for perineal hygiene:

1. Increase tissue perfusion — promotes oxygen delivery and waste removal at the wound site, accelerating healing
2. Prevent infection — the perineum is in proximity to the urethra, vagina, and anus; bacteria from each can contaminate the wound. Hand hygiene, front-to-back wiping, and squeeze bottle cleansing minimize cross-contamination
3. Promote comfort — perineal pain reduces ambulation, voiding, bonding, and breastfeeding success. Adequate comfort is a clinical priority, not just emotional support

Why front to back? The urethra (clean) is anterior; the anus (contaminated) is posterior. Wiping back to front transfers bacteria from anus to urethra/vagina/wound → ↑ UTI and wound infection.

Why blot, not wipe? Friction can disrupt sutures and traumatize edematous tissue. Blotting cleans without mechanical injury.

Client actions to prevent infection (4):

• Wash hands thoroughly before and after voiding
• Use a squeeze bottle (peri bottle) with warm water or antiseptic solution after each voiding
• Clean the perineal area from front to back (urethra to anus)
• Blot dry — do not wipe
• Use topical antiseptic cream or spray sparingly
• Change perineal pad from front to back after voiding/defecating
• Avoid tampons (↑ infection risk)

Nurse actions to promote comfort (4):

• Apply ice or cold packs to the perineum (first 24 hr; never directly to skin)
• Encourage sitz baths at least twice a day (≥ 20 min, hot or cool temperature)
• Administer analgesics as prescribed (acetaminophen, ibuprofen, opioids if needed)
• Apply topical anesthetics (benzocaine spray) to perineal area
• Apply witch hazel compresses to rectal area for hemorrhoids
• Heat therapy / moist heat after first 24 hr to ↑ circulation and healing

Documentation & teaching:

• Document REEDA findings each shift
• Teach signs to report: increased pain, foul-smelling discharge, separation of suture line, fever > 38°C
• Reinforce hygiene and pad-change technique at every patient encounter

Three ways the father develops a parent-infant bond:

• Touching, holding, skin-to-skin contact, and maintaining eye-to-eye contact
• Recognizing personal features in the infant and validating his claim to the infant
• Talking, reading, singing, and verbally interacting with the newborn

Context — what the father may experience:

• Initially has preconceived expectations of fatherhood
• May feel sadness, frustration, or jealousy when reality doesn't match expectations
• May feel unable to talk with the other parent (consumed with caregiving)
• Eventually decides to actively engage in care
• Reaps rewards: infant smiles, completeness, meaning

Three stages of paternal transition to parenthood:

1. Expectations: having preconceived ideas about fatherhood
2. Reality: recognizing that expectations might not be met, facing these feelings, and embracing the need to become actively involved in parenting
3. Transition to mastery: taking an active role in parenting

Three stages of father-infant bond development:

1. Making a commitment and assuming responsibility for parenting
2. Becoming connected and having feelings of attachment to the newborn
3. Modifying lifestyle to make room to care for the newborn

Why this matters: Co-parents face a transition that can include emotional challenges similar to but distinct from the birthing parent's. Acknowledging the legitimacy of paternal adaptation supports family-centered care and improves long-term parental engagement.

Three actions to assist in the father-infant bonding process:

1. Provide education about newborn care when the father is present (don't deliver teaching only when the birthing parent is present)
2. Encourage the father to take a hands-on role in care when present
3. Provide guidance as the father builds skill and confidence

Additional interventions:

• Involve the father as a full partner, not a helper, in the parenting process
• Encourage the couple to verbalize concerns and expectations about newborn care
• Facilitate skin-to-skin opportunities for the father (especially in cases of cesarean recovery or maternal complications)
• Validate paternal experiences and emotions; normalize ambivalence and adjustment difficulty
• Connect to peer support groups for new fathers when available
• Document paternal-infant interactions and any concerns

Lactation suppression for the nonlactating client:

• Wear well-fitting, supportive bra continuously for first 72 hours
• Avoid breast stimulation and warm water over breasts
• Cold compresses 15 min on, 45 min off for engorgement
• Cabbage leaves inside the bra
• Mild analgesics for engorgement pain

Activity:

• Pelvic tilt and Kegel exercises
• Vaginal: limit stair climbing first few weeks
• Cesarean: 4–6 weeks before strenuous exercise; 1 flight stairs/day; < 10 lb lifting × 2 weeks
• Plan ≥ 1 daily rest period

Contraception:

• Menses may resume 4–10 weeks; ovulation as early as 1 month
• Contraception needed before resuming sexual activity

Follow-up: 4–6 weeks after vaginal birth · 2 weeks after cesarean

Nutrition:

• Eat a diet that includes all food groups and higher protein content
• Drink fluids to satisfy thirst
• Consume 1,800–2,200 kcal/day

Resumption of sexual intercourse:

• Safely resume by 2nd to 4th week after birth, when bleeding has stopped and perineum has healed
• OTC lubricants might be needed
• Physiological reactions to sexual activity can be slower and less intense for the first 3 months

Why teach all of this: Discharge instructions support self-care competence, infection prevention, recovery progression, and recognition of complications. Verifying understanding via teach-back / return demonstration ensures actionable retention.

The client should report the following to the provider:

• Chills or fever > 38°C (100.4°F) for 2 or more days
• Change in vaginal discharge: increased amount, large clots, change to previous lochia color, foul odor
• Episiotomy, laceration, or incisional pain not resolving with analgesics; foul-smelling drainage; redness; edema
• Pain or tenderness in abdominal or pelvic area not resolving with analgesics
• Localized breast pain + heat + swelling; nipple cracks or fissures (mastitis)
• Calves with localized pain, tenderness, redness, swelling; lower extremity redness/warmth (DVT)
• Burning, pain, frequency, urgency on urination (UTI)
• Indications of possible depression: apathy toward infant, cannot provide self/infant care, feelings of harming self or infant

Documentation: ensure client has the date and time of follow-up appointment in writing and a number to call with concerns.

Why airway clearance matters in newborns:

• Newborns have small airways and produce mucus during transition to extrauterine life
• Cesarean newborns are more susceptible to retained fluid in lungs than vaginally delivered (no thoracic squeeze during birth)
• Newborns are obligate nose breathers until ~3 weeks → nasal blockage causes flaring, cyanosis, asphyxia
• The 2nd period of reactivity (2–8 hr after birth) is when newborns commonly gag/choke on accumulated mucus

Signs of respiratory distress requiring intervention:

• Bradypnea (RR ≤ 30) or tachypnea (RR ≥ 60)
• Expiratory grunting
• Crackles, wheezes
• Nasal flaring
• Retractions
• Gasping, labored breathing
• Apnea > 15 seconds

Family teaching: bulb syringe should remain with newborn at all times. Family demonstrates technique back to nurse before discharge.

1. Infant's cough reflex
   • Newborn is able to clear most secretions in air passages by the cough reflex
   • The cough reflex is part of normal newborn physiology and the first-line clearance mechanism
2. Mechanical suctioning
   • If bulb suctioning is unsuccessful, mechanical suction is used for clearing the airway
   • Emergency procedures instituted if airway does not clear
3. Use of the bulb syringe for suctioning
   • Routine use to remove excess mucus in the respiratory tract
   • Performed on mouth first, then nasal passages

Why mouth before nose? When the nose is suctioned first, the stimulation can trigger a gasp reflex that aspirates whatever is pooled in the mouth. Suctioning mouth first ensures no oral secretions are present to be aspirated when nasal stimulation occurs.

Stepwise technique:

1. Compress (depress) bulb BEFORE insertion
   • Inserting an uncompressed bulb forces air into the airway, which can push secretions deeper
2. Insert syringe into the side of the mouth
   • Avoid the center of the mouth — prevents stimulating the gag reflex
3. Aspirate mouth first, then one nostril, then second nostril
   • Mouth before nose prevents aspiration when nasal stimulation triggers a gasp
4. Release bulb to draw secretions in
5. Remove bulb from mouth/nose; expel secretions onto a clean tissue or cloth by compressing bulb sharply
6. Repeat as needed; observe respiratory pattern after each pass
7. Clean bulb syringe per facility policy

Family teaching points:

• Demonstrate technique to family
• Have family return-demonstrate before discharge
• Keep bulb syringe with newborn (in bassinet, diaper bag)
• Use only when needed (mucus visible, gagging, distress) — NOT routinely after every feeding
• Notify provider if bulb suctioning doesn't relieve respiratory difficulty

Three types of breast pumps:

• Manual
• Electric
• Battery-operated

Use of the pump:

• Pumping of one or both breasts
• Adjustable suction for comfort
• Pumped directly into a bottle or freezer bag
• Used to obtain breast milk for storage and later feeding

Why pump?

• Allows continued BF when separated from infant (work, illness)
• Maintains supply during temporary cessation of direct BF
• Provides expressed milk if supplementation is needed (preferred over formula)
• Relieves engorgement

Breast milk must be stored according to guidelines for proper containers, labeling, refrigerating, and freezing.

Storage durations:

• Room temperature under very clean conditions: up to 8 hours
• Refrigerated in sterile bottles: use within 8 days
• Frozen in freezer compartment of refrigerator in sterile containers: up to 6 months
• Deep freezer: up to 12 months

Container/labeling tips:

• Use sterile containers
• Label with date and amount
• Use oldest stored milk first ("first in, first out")
• Don't fill containers more than ¾ full (allow for expansion when frozen)

Procedures for thawing milk:

• Thaw milk in the refrigerator for 24 hr — best method (preserves immunoglobulins)
• Hold container under running lukewarm water OR place in container of lukewarm water
• Bottle should be rotated, but NOT shaken (shaking can damage milk components)
• DO NOT thaw in microwave
  • Destroys immune factors and lysozymes
  • Creates hot spots due to uneven heating → can burn newborn

After thawing:

• Do NOT refreeze thawed milk
• Discard unused portions after thawing or warming
• Use within 24 hr of thawing in refrigerator

Why these rules matter: Breast milk's immune-protective properties (IgA, lysozymes, leukocytes, macrophages, lactoferrin) are heat-sensitive. Refrigerator thawing preserves these factors; microwave heating destroys them and creates burn risk from uneven heating. The "no shaking" rule preserves the lipid structure of the milk.

Skin care:

• The eyes are cleaned using a clean portion of the wash cloth (use a different section of cloth for each eye)
• The newborn should be washed, rinsed, and dried with no soap left on the skin
• Apply fragrance-free, hypoallergenic, moisturizing emollient immediately after bathing to prevent dry skin

Infant safety:

• Do not leave the newborn unattended during the bath (single most important safety rule)
• Hot water heater should be set at 49°C (120.2°F) or less to prevent scalding
• Room should be warm; bath water 36.6–37.2°C (98–99°F)
• Bath water should be tested on the inner wrist (or elbow) prior to use
• Organize all equipment so the newborn isn't left unattended to retrieve supplies

Move from the cleanest to the dirtiest areas of the newborn's body:

1. Eyes — clean portion of the wash cloth; use clear water; move from inner canthus to outer canthus; new cloth section for each eye
2. Face and head — wash gently; rinse
3. Chest, arms, legs — wash, rinse, dry; ensure no soap is left on skin
4. Groin LAST — perineal area is the dirtiest; saving it for last prevents transferring bacteria to cleaner areas

Why this order matters: Bathing cleanest to dirtiest prevents bacteria from the perineum from being spread to the eyes, face, or other body parts. Working systematically also reduces risk of missing areas and shortens total bath time (less heat loss).

Other technique points:

• Wrap newborn in a towel; swaddle in a football hold to shampoo the head
• Rinse shampoo and dry to avoid chilling
• Expose only the body part being bathed; dry thoroughly

Key prevention measures:

• Bathing by immersion is NOT done until the umbilical cord falls off and the circumcision is healed
  • Until then: sponge bath only
  • Wash around cord; do not get cord wet
• Do NOT bathe newborn immediately after feeding — prevents spitting up and vomiting
• Uncircumcised newborn: foreskin should NOT be forced back — constriction can result; clean what is exposed only
• Female newborns: wash the vulva by wiping from front to back — prevents contamination of the vagina or urethra from rectal bacteria

Genital cleansing summary:

• Uncircumcised penis: soap and water; rinse; do NOT retract foreskin
• Circumcised penis (post-procedure): warm water only; NO soap until healed
• Vulva: front to back, every diaper change and bath

Risk to monitor: chilling and heat loss → cold stress. Keep room warm, expose only the part being washed, and dry thoroughly between body areas.

Standardized assessment at 1 and 5 minutes after birth — repeated every 5 min if score < 7 until 20 min or score normalizes. Evaluates 5 parameters, each scored 0–2 (max 10).

Five parameters (mnemonic APGAR):

• Appearance (color): 2 = pink all over · 1 = body pink, extremities blue (acrocyanosis) · 0 = pale or blue
• Pulse (HR): 2 = > 100 · 1 = < 100 · 0 = absent
• Grimace (reflex irritability to stimulus): 2 = cry, sneeze, cough · 1 = grimace · 0 = no response
• Activity (muscle tone): 2 = active motion, flexed · 1 = some flexion · 0 = limp
• Respirations: 2 = strong cry, regular · 1 = weak, irregular · 0 = absent

Score interpretation:

• 7–10 = good condition (most newborns; routine care)
• 4–6 = moderate distress (stimulation, supplemental O₂, possible bag/mask)
• 0–3 = severe distress (resuscitation required immediately)

Key principles:

• Resuscitation does NOT wait for Apgar score
• 5-min score correlates more closely with neurologic outcome than 1-min
• Score may be affected by gestational age, maternal medications, congenital anomalies
• Apgar score is not a predictor of long-term outcomes alone
• Color (Appearance) most subjective — acrocyanosis common and normal first 24 hr

Score 7–10 (normal):

• Dry, warm, position
• Skin-to-skin with mother if stable
• Initiate feeding within 1 hour

Score 4–6 (moderate):

• Stimulate by drying, rubbing back
• Supplemental oxygen via blow-by
• Suction airway if obstructed
• Consider PPV (positive pressure ventilation) with bag-mask
• Reassess every 30 sec

Score 0–3 (severe):

• Immediate PPV with 100% O₂
• Chest compressions if HR < 60 after 30 sec PPV
• Call neonatal resuscitation team / code
• Establish IV access for medications
• Consider intubation, epinephrine, volume expansion

Document score, time of assessment, and any interventions performed.

Primitive reflexes present at birth indicate intact neurological function. Most disappear in early infancy. Absence, asymmetry, or persistence beyond expected age may indicate neurologic dysfunction.

Major reflexes assessed (and disappearance age):

• Sucking — disappears 3–4 months
• Rooting — disappears 3–4 months
• Palmar grasp — disappears 3–4 months
• Plantar grasp — disappears 8 months
• Moro (startle) — disappears 3–4 months
• Babinski — disappears 12 months (toes fan up normally)
• Tonic neck (fencing) — disappears 3–4 months
• Step / dance — disappears 3–4 weeks
• Galant (truncal incurvation) — disappears 4 weeks

How to elicit each reflex:

• Sucking: stroke lips or insert nipple — infant sucks rhythmically
• Rooting: stroke cheek/corner of mouth — infant turns head toward stimulus and opens mouth
• Palmar grasp: place finger in palm — infant tightly grasps
• Plantar grasp: place finger at base of toes — toes curl down
• Moro: sudden change of position or loud noise — symmetric abduction/extension of arms, hands open, then flexion ('hugging')
• Babinski: stroke lateral sole heel to toe — toes fan and dorsiflex (positive in infant — abnormal in adult)
• Tonic neck: turn head to one side while supine — same-side arm extends, opposite arm flexes ('fencing position')
• Step: hold upright, feet touching surface — infant makes stepping motions
• Galant: stroke one side of back along spine — trunk curves toward stimulated side

Significance of findings:

• Absent reflexes may indicate CNS depression (asphyxia, sedation), neurologic damage, or prematurity
• Asymmetric reflexes may indicate brachial plexus injury, fracture, hemiparesis
• Persistent reflexes beyond expected disappearance — cerebral palsy, neurological disorder

Who to assess:

• All newborns at initial assessment
• Daily during nursery stay
• At well-child visits per pediatric schedule

How to assess:

• Perform when infant is calm, alert (best 30–60 min after feed)
• Test all reflexes systematically
• Test bilaterally and compare sides
• Avoid testing immediately after feeding (regurgitation risk with Moro)

Why it matters:

• Documents neurologic status at birth
• Identifies need for further evaluation
• Baseline for comparison over time
• Reassurance to parents

Document findings: present/absent, symmetric/asymmetric, strength of response.

Report any abnormalities (absent, asymmetric, or weak reflexes) to provider for further evaluation.

Decelerations are decreases in fetal heart rate from baseline. Classification based on timing relative to contractions, depth, and shape. Use the VEAL CHOP MINE mnemonic:

• Variable decels — Cord compression — Move (reposition mother)
• Early decels — Head compression — Identify labor progress (no intervention needed)
• Accelerations — Okay — No intervention (reassuring)
• Late decels — Placental insufficiency — Execute interventions (intrauterine resuscitation)

Each pattern characteristics:

• Early decel: gradual decrease & return, mirror image of contraction, nadir at peak of contraction, depth usually < 30 BPM. Benign.
• Variable decel: abrupt decrease (< 30 sec to nadir), ≥ 15 BPM below baseline, ≥ 15 sec but < 2 min. Shape and timing vary.
• Late decel: gradual decrease, nadir AFTER peak of contraction, return to baseline AFTER contraction ends. Concerning.
• Prolonged decel: decrease > 15 BPM below baseline lasting 2–10 min. Concerning if recurrent or severe.

Physiologic basis of each pattern:

• Early — Head compression: vagal stimulation from fetal head compression during contraction. Normal in active labor.
• Variable — Cord compression: umbilical cord compression intermittently impairs umbilical blood flow. May occur with oligohydramnios, cord around neck, prolapsed cord.
• Late — Placental insufficiency: contraction reduces uteroplacental blood flow; if insufficient placental reserve, fetus experiences transient hypoxia. Ominous sign of fetal hypoxia/acidosis.
• Prolonged — Multiple causes: tetanic contraction, maternal hypotension (epidural), cord prolapse, abruption, uterine rupture, vagal stimulation.

FHR categories (ACOG):

• Category I (Normal): baseline 110–160, moderate variability, accelerations present, no late or variable decels
• Category II (Indeterminate): not Cat I or Cat III; requires evaluation and intervention
• Category III (Abnormal): absent variability with recurrent late decels, recurrent variable decels, bradycardia, OR sinusoidal pattern. Urgent intervention or delivery required.

Intrauterine resuscitation interventions (LION mnemonic):

• Lateral position (left side first)
• IV fluid bolus (LR 500 mL)
• Oxygen 10 L/min via nonrebreather mask
• Notify provider; discontinue oxytocin

Early decels — NO intervention needed:

• Document and continue monitoring
• Reassure client these are normal
• Identify cervical dilation if not recently checked

Variable decels — REPOSITION:

• Reposition mother (left lateral first, then right, then hands-knees if persistent)
• Consider amnioinfusion if persistent and oligohydramnios suspected
• Vaginal exam to rule out cord prolapse if severe
• Discontinue oxytocin if running
• Document interventions and response

Late decels — INTRAUTERINE RESUSCITATION:

• Discontinue oxytocin immediately
• Reposition mother (left lateral)
• IV fluid bolus (LR 500–1,000 mL)
• Oxygen 10 L/min via face mask
• Notify provider STAT
• Treat hypotension if present (ephedrine if epidural-related)
• Consider tocolysis (terbutaline 0.25 mg SC) if tachysystole
• Prepare for delivery if persistent (cesarean if no response)

Prolonged decels — RAPID ASSESSMENT:

• All interventions above
• Vaginal exam for cord prolapse, rapid cervical change, abruption signs
• Assess maternal VS for hypotension
• Stop oxytocin
• Prepare for emergency cesarean if not resolving
• Document interventions, timing, and FHR response carefully

Recommended weight gain in pregnancy is based on PRE-PREGNANCY BMI per the Institute of Medicine (IOM) guidelines. Inadequate weight gain → IUGR, low birth weight, preterm birth. Excessive weight gain → macrosomia, gestational diabetes, hypertension, cesarean delivery, postpartum weight retention.

IOM Weight Gain Recommendations (Singleton)

• Underweight (BMI < 18.5): 28–40 lb (12.7–18.1 kg)
• Normal weight (BMI 18.5–24.9): 25–35 lb (11.3–15.9 kg)
• Overweight (BMI 25.0–29.9): 15–25 lb (6.8–11.3 kg)
• Obese (BMI ≥ 30): 11–20 lb (5.0–9.1 kg)

Distribution of Weight Gain

• First trimester: 1–4.4 lb (0.5–2 kg) total
• Second/third trimester: weekly gain depending on BMI
• Normal BMI: 0.8–1.0 lb/week
• Underweight: 1.0–1.3 lb/week
• Overweight: 0.5–0.7 lb/week
• Obese: 0.4–0.6 lb/week

Multifetal Gestation Weight Gain

• Twins (normal BMI): 37–54 lb
• Twins (underweight): 50–62 lb
• Twins (overweight): 31–50 lb
• Twins (obese): 25–42 lb

Where the weight goes (~25-35 lb total):

• Fetus: 7–8 lb (3.2–3.6 kg)
• Placenta: 1–2 lb (0.5–1 kg)
• Amniotic fluid: 2 lb (1 kg)
• Uterine enlargement: 2 lb (1 kg)
• Maternal breast tissue: 1–3 lb (0.5–1.4 kg)
• Maternal blood volume: 3–4 lb (1.4–1.8 kg)
• Body fluids (increased): 2–3 lb (1–1.4 kg)
• Maternal fat stores: 5–9 lb (2.3–4.1 kg) — energy reserves for breastfeeding

Pattern of Weight Gain

• Most weight gain occurs in 2nd and 3rd trimesters
• Slow or no gain in 1st trimester is normal (nausea, vomiting)
• Steady weekly weight gain expected from 2nd trimester onward
• Sudden weight gain (> 2 lb/week, > 6 lb/month) → assess for preeclampsia (fluid retention)

Caloric Requirements by Trimester

• 1st trimester: No increase needed (~2,000 cal/day for average)
• 2nd trimester: +340 cal/day
• 3rd trimester: +452 cal/day
• Lactation: +450–500 cal/day (per AAP)

Consequences of Inappropriate Weight Gain

• Inadequate gain: IUGR, low birth weight, preterm birth, increased perinatal mortality
• Excessive gain: macrosomia (> 4,000 g), shoulder dystocia, cesarean, gestational diabetes, preeclampsia, postpartum obesity, future childhood obesity in offspring

Assessment at every prenatal visit:

• Calculate pre-pregnancy BMI from history
• Weigh at each visit (consistent scale, similar clothing)
• Plot weight on appropriate growth chart
• Compare to expected gain trajectory
• Assess for symmetry (steady gain vs sudden gain)

Nutrition Counseling

• Provide BMI-specific recommendations to client
• Encourage variety: fruits, vegetables, whole grains, lean protein, low-fat dairy
• Discourage empty calories: sugary drinks, processed foods, fast food
• Adequate fluid intake (2.3 L/day)
• Address cravings, food aversions, pica
• Refer to dietitian if significantly off trajectory
• Refer to WIC if food insecurity

For Inadequate Weight Gain

• Assess for nausea/vomiting, hyperemesis, eating disorder
• Dietary counseling: small frequent meals, calorie-dense foods
• Address underlying medical conditions
• Treat eating disorders
• Monitor fetal growth (serial ultrasounds)

For Excessive Weight Gain

• Never recommend weight loss during pregnancy
• Aim to slow rate of gain to appropriate weekly target
• Increase moderate exercise (walking 30 min/day)
• Limit added sugars, fats, processed foods
• Portion control education
• Screen for gestational diabetes
• Monitor BP for preeclampsia

Sudden Weight Gain — Red Flag

• Gain > 2 lb/week → assess for preeclampsia
• Check BP, urine protein
• Assess for face/hand edema (vs dependent edema, which is normal)
• Ask about headache, visual changes, RUQ pain

The Bishop Score is a system used to predict the likelihood of successful induction of labor based on cervical readiness. Higher scores indicate the cervix is more favorable ("ripe") for induction.

Bishop Score Parameters (Total 0-13)

Score Interpretation

• Score ≥ 8 (favorable): cervix is ripe; induction likely successful with similar duration to spontaneous labor
• Score 6–7 (intermediate): induction may proceed; consider cervical ripening for better success
• Score < 6 (unfavorable): cervical ripening agents recommended before induction; higher failure rate

Why Bishop Score Matters:

• Predicts duration of induction
• Predicts likelihood of cesarean delivery
• Identifies clients who would benefit from cervical ripening before oxytocin
• Helps with clinical decision-making and patient counseling

Understanding Each Parameter

• Dilation: how open the cervical os is (closed → 10 cm)
• Effacement: thinning of cervix (0-100%)
• Station: relationship of presenting part to ischial spines (-5 to +5; 0 = engaged)
• Consistency: firm (like nose) → medium → soft (like lip)
• Position: posterior → mid → anterior (anterior more favorable)

When Bishop Score is Used

• Before elective induction of labor
• To assess cervical readiness for VBAC
• To decide between cervical ripening agents vs direct oxytocin
• To counsel about likelihood of successful vaginal delivery

Cervical Ripening Options for Low Bishop Scores

• Prostaglandins:
  • Dinoprostone (Cervidil 10 mg vaginal insert; Prepidil 0.5 mg gel)
  • Misoprostol (Cytotec) 25 mcg PO/PV q4hr — contraindicated in prior cesarean
• Mechanical methods:
  • Foley balloon catheter (30-60 mL)
  • Cook balloon (double-balloon)
  • Laminaria (hygroscopic dilators)
  • Membrane stripping

Assessment of Bishop Score:

• Performed via sterile vaginal exam
• Score each parameter individually
• Add all parameters for total score
• Document time, score, indication for assessment
• Combine with patient history and overall clinical picture

Nursing Care for Cervical Ripening

• Pre-procedure:
  • Verify informed consent
  • NPO if procedure may lead to delivery
  • Baseline FHR and contraction monitoring
  • IV access
  • Empty bladder
• During/After Cervical Ripening Agent:
  • Continuous EFM × 30 min to 2 hours post-insertion
  • Lie supine or lateral × 30 min post-insertion
  • Monitor for tachysystole (> 5 contractions in 10 min)
  • Monitor for non-reassuring FHR pattern
  • Watch for ROM
  • If Cervidil: can remove immediately if complications
  • If misoprostol: cannot be removed
• Begin oxytocin no sooner than 4 hr after last dinoprostone dose

Mechanical Methods (Foley Balloon)

• Safe in clients with prior cesarean
• Insert via sterile vaginal exam
• Inflate balloon with 30-60 mL saline
• Apply gentle traction (taped to leg)
• Falls out when dilation reaches 3-4 cm
• Maximum 24 hr placement
• Less risk of tachysystole than prostaglandins

Patient Education

• Explain the procedure and expectations
• Mild cramping is expected
• Goal is to soften and open the cervix before active induction
• May take 12-24 hours to achieve favorable cervix
• Once cervix is favorable, oxytocin may be started
• Report: severe pain, heavy bleeding, ROM, decreased fetal movement

Pregnancy produces a wide range of physiologic discomforts from hormonal changes, growing uterus, increased blood volume, and changes in body mechanics. Most are normal but require management to maintain quality of life. Some require differentiation from pathologic conditions.

First Trimester (Weeks 1-12)

• Nausea and vomiting (50-80% of clients; "morning sickness")
• Fatigue, sleepiness (high progesterone)
• Urinary frequency (uterine pressure on bladder)
• Breast tenderness and enlargement
• Increased vaginal discharge (leukorrhea)
• Nasal stuffiness, epistaxis
• Ptyalism (excessive salivation)

Second Trimester (Weeks 13-26)

• Heartburn / GERD
• Constipation, hemorrhoids
• Round ligament pain (sharp groin pain)
• Backache (especially low back)
• Leg cramps (especially nocturnal)
• Varicose veins
• Skin changes (chloasma, linea nigra, striae gravidarum)

Third Trimester (Weeks 27-40)

• Shortness of breath (diaphragm elevation)
• Dependent edema
• Insomnia, sleep disturbances
• Braxton-Hicks contractions
• Returning urinary frequency
• Pelvic pressure
• Carpal tunnel syndrome
• Lightening (descent of presenting part)

Pathophysiology of Pregnancy Discomforts:

• Hormonal effects: hCG, progesterone, and estrogen affect smooth muscle, GI motility, vasculature
• Mechanical effects: growing uterus displaces organs, alters posture and gait
• Hemodynamic changes: increased blood volume, decreased peripheral resistance affect venous return
• Metabolic changes: increased nutrient demands, altered glucose metabolism

When Discomforts Become Red Flags

• Severe nausea/vomiting → hyperemesis gravidarum (weight loss > 5%, ketonuria, dehydration)
• Severe headache + visual changes → preeclampsia (NOT a normal pregnancy discomfort)
• Sudden weight gain, facial/hand edema → preeclampsia
• Painful, unilateral leg swelling → DVT
• Vaginal bleeding → abruption, previa, preterm labor
• Sudden gush of fluid → ROM
• Regular painful contractions before 37 wk → preterm labor
• Severe abdominal pain → abruption, ectopic, uterine rupture
• Decreased fetal movement → fetal distress

Pharmacologic Considerations

• Most OTC medications avoided unless approved by HCP
• Safe in pregnancy: acetaminophen, certain antacids (calcium-based), pyridoxine (B6), doxylamine, certain antihistamines (diphenhydramine, loratadine), simethicone
• Avoid: aspirin (3rd tri), ibuprofen/NSAIDs, decongestants with phenylephrine/pseudoephedrine, bismuth subsalicylate, sodium bicarbonate antacids

First Trimester Management:

• Nausea/vomiting: small frequent meals; dry crackers before getting up; ginger 250 mg QID; pyridoxine (B6) 25 mg TID; doxylamine-pyridoxine (Diclegis) if severe; acupressure bands; avoid empty stomach
• Fatigue: 8-10 hr sleep, naps, prioritize rest, light exercise
• Urinary frequency: continue fluid intake during day, decrease evening fluids, void completely
• Breast tenderness: supportive bra (sports bra), gentle warm shower
• Leukorrhea: cotton underwear, panty liners, NO douching, good hygiene
• Nasal stuffiness: humidifier, saline nasal spray, avoid decongestants

Second Trimester Management

• Heartburn: small frequent meals, no eating before bed, head of bed elevated, calcium-based antacids (Tums), AVOID sodium bicarbonate
• Constipation: 25-30 g fiber/day, 2.3 L fluid/day, exercise, docusate sodium, NO stimulant laxatives, NO mineral oil
• Hemorrhoids: stool softeners, witch hazel pads (Tucks), sitz baths, topical hydrocortisone (short-term), avoid prolonged sitting
• Round ligament pain: slow position changes, bend knees toward abdomen, support belt, warm compress (NOT hot)
• Backache: pelvic tilt exercises, proper body mechanics, low-heeled shoes, support pillow, prenatal massage
• Leg cramps: dorsiflex foot with knee extended, calcium and magnesium intake, avoid pointing toes, warm bath
• Varicose veins: elevate legs frequently, compression stockings, avoid prolonged standing, NO crossing legs

Third Trimester Management

• Dyspnea: semi-Fowler position, extra pillows when sleeping, slow movements
• Edema: elevate feet, left lateral position, compression stockings, adequate hydration; differentiate from preeclampsia
• Insomnia: side-lying with pillow between legs, warm bath, no caffeine, relaxation techniques
• Braxton-Hicks: hydration, position change, walking; assess for preterm labor if regular/painful
• Carpal tunnel: wrist splints (especially night), ice, NSAIDs only with HCP approval
• Pelvic pressure: normal with engagement; reposition, pelvic rocking exercises

TORCH is a mnemonic for a group of infections that can cross the placenta and cause significant congenital infection, fetal anomalies, or stillbirth. Often asymptomatic in the mother but devastating to the fetus.

TORCH Components

• T — Toxoplasmosis (Toxoplasma gondii)
• O — Other (HBV, HIV, syphilis, parvovirus B19, varicella, Zika, listeria)
• R — Rubella
• C — Cytomegalovirus (CMV)
• H — Herpes Simplex Virus (HSV)

Common Congenital Effects Across TORCH

• Intrauterine growth restriction (IUGR)
• Microcephaly
• Hepatosplenomegaly
• Jaundice
• Petechiae, purpura ("blueberry muffin rash")
• Hearing/vision impairment
• Neurodevelopmental delays
• Cardiac defects

Specific Infections in Detail:

Toxoplasmosis

• Source: raw/undercooked meat, unwashed produce, cat litter (oocysts)
• Maternal symptoms: often asymptomatic; flu-like illness
• Fetal effects: chorioretinitis, hydrocephalus, intracranial calcifications, hepatosplenomegaly, mental retardation
• Treatment: Spiramycin (1st tri); pyrimethamine + sulfadiazine + folinic acid (after 16 wk)

Rubella (German Measles)

• Source: respiratory droplets
• Maternal symptoms: low-grade fever, rash, lymphadenopathy
• Fetal effects (Congenital Rubella Syndrome): deafness, cataracts, cardiac defects (PDA), microcephaly, IUGR — worst if infected 1st trimester (50%)
• Vaccine: LIVE — give postpartum if non-immune; avoid pregnancy × 4 weeks
• No specific treatment — supportive only

Cytomegalovirus (CMV)

• Most common congenital infection
• Source: body fluids (saliva, urine, sexual contact); often acquired from toddlers
• Maternal symptoms: usually asymptomatic; may have mono-like illness
• Fetal effects: hearing loss (MOST COMMON sequela), microcephaly, intracranial calcifications, hepatosplenomegaly, learning disabilities
• No vaccine or effective treatment
• Prevention: hand hygiene around children, avoid sharing utensils/cups

Herpes Simplex Virus (HSV)

• HSV-2 (genital) and HSV-1 (oral, increasingly genital)
• Risk to fetus highest with PRIMARY maternal infection during pregnancy
• Neonatal HSV: skin/eye/mouth disease, CNS disease (encephalitis), disseminated disease (50% mortality)
• Active genital lesions at time of labor → cesarean delivery
• Suppressive therapy: acyclovir 400 mg TID from 36 weeks for recurrent HSV

Screening at First Prenatal Visit:

• Rubella titer — IgG (immunity); if non-immune, vaccinate postpartum
• HSV history — primary or recurrent outbreaks?
• CMV — not routine; consider in high-risk (childcare workers, parents of toddlers)
• Toxoplasmosis — IgG/IgM if exposure history; not routine in US
• Other: HIV, HBsAg, syphilis (RPR), varicella history/titer

Prevention Education

• Toxoplasmosis:
  • Avoid raw/undercooked meat (cook to 165°F)
  • Wash all fruits and vegetables thoroughly
  • Avoid cat litter changing (if must, wear gloves; have someone else change litter daily)
  • Gardening with gloves
  • Avoid contact with cat feces or stray cats
• CMV:
  • Frequent hand hygiene, especially after diapering, feeding, wiping noses
  • Don't share utensils, cups, food, toothbrushes with young children
  • Don't kiss children on the mouth
  • Clean toys, surfaces frequently
• Rubella:
  • Pre-conception vaccination if non-immune
  • Avoid contact with anyone with viral rash illness
  • Avoid travel to areas with rubella outbreaks
• HSV:
  • Disclose history at first prenatal visit
  • Use condoms with partner who has HSV
  • Avoid oral sex with partner who has cold sores
  • Suppressive therapy from 36 weeks for recurrent genital HSV
  • Inspect for lesions at labor onset

Management of Suspected/Confirmed Infection

• Document specific organism and gestational age at infection
• Maternal serology (IgG, IgM)
• Consider amniocentesis for fetal diagnosis (PCR)
• Detailed ultrasound for fetal abnormalities
• Fetal MRI in selected cases
• Genetic counseling and pediatric infectious disease consultation
• Postpartum: newborn evaluation with cultures, PCR, ophthalmology, audiology

BUBBLE-HE is a systematic head-to-toe mnemonic for postpartum assessment. Performed at intervals: q15 min × 1 hr after delivery, q30 min × 1 hr, q4 hr × 24 hr, then per institutional protocol. Identifies complications early.

The BUBBLE-HE Mnemonic

• B — Breasts
• U — Uterus (fundus)
• B — Bladder
• B — Bowel
• L — Lochia
• E — Episiotomy / Epidural site / Edema
• H — Homans sign / Hemorrhoids
• E — Emotions / Education

Some versions include "Lower extremities" for the second L position; principles are the same.

What to Assess in Each Component:

B — Breasts

• Day 1-2: soft, colostrum production
• Day 3-5: milk "comes in" — full, firm, possibly tender (engorgement)
• Assess: shape, symmetry, nipples (everted/inverted/flat/cracked), tenderness, redness, warmth, masses
• Latch and feeding (if breastfeeding)
• Watch for: mastitis (unilateral redness, warmth, fever), plugged duct, severe engorgement

U — Uterus (Fundus)

• Assess: location (above/at/below umbilicus), midline vs deviated (deviation = full bladder), firmness (firm/boggy)
• Expected involution: 1 cm below umbilicus each day; non-palpable by day 10-14
• If boggy: massage firmly; if doesn't firm → uterotonics, notify provider
• If deviated: have client void, then reassess

B — Bladder

• Assess: ability to void, void volume, postvoid residual
• First void within 6-8 hours postpartum (catheterize if not)
• Distended bladder displaces uterus → atony, hemorrhage
• Risk of retention from epidural, bladder hypotonia, edema

B — Bowel

• Bowel sounds, last BM, flatus
• Expected: first BM by day 2-3
• Often delayed by perineal pain, opioids, slow peristalsis
• Stool softener (docusate) for prevention of constipation

L — Lochia

• Assess: amount, color, odor, presence of clots
• Quantification: Scant (< 2.5 cm) → Light (2.5-10 cm) → Moderate (> 10 cm, < pad) → Heavy (full pad in 2 hr)
• Progression: Rubra (days 1-3) → Serosa (days 4-10) → Alba (days 11-21+)
• Reassessment after voiding (full bladder can mask blood)
• Saturating pad < 1 hr → hemorrhage

E — Episiotomy / Epidural / Edema

• REEDA: Redness, Edema, Ecchymosis, Discharge, Approximation
• Epidural site: hematoma, redness, drainage
• Perineal edema: ice × 12-24 hr, then sitz baths
• Hematomas: severe pain, perineal mass, hypotension out of proportion to visible blood loss

H — Homans Sign / Hemorrhoids

• Assess legs for: warmth, redness, swelling, tenderness, asymmetry
• Homans sign: calf pain on dorsiflexion (controversial; low sensitivity)
• Postpartum has 5× DVT risk in pregnancy, 20× in immediate postpartum
• Hemorrhoids: assess size, tenderness, bleeding; topical agents, sitz baths

E — Emotions / Education

• Mood, attachment behaviors, family interaction
• Screen for postpartum blues vs depression (EPDS)
• Concerns or questions
• Sleep quality and amount
• Identify learning needs: newborn care, self-care, return to activity

Documentation:

• Date, time of each assessment
• Each component of BUBBLE-HE documented
• Fundal height (in fingerbreadths or cm), position, consistency
• Lochia: amount, color, odor, clots
• Any abnormal findings + interventions + response

Frequency of Assessment

• 1st hour: every 15 minutes
• 2nd hour: every 30 minutes
• Next 22 hours: every 4 hours
• After 24 hours: every shift or per protocol
• More frequent if abnormalities

Red Flags Requiring Immediate Action

• Boggy fundus that doesn't firm with massage → uterotonics, notify provider
• Saturated pad in < 1 hr → hemorrhage protocol
• Heavy bleeding with firm fundus → cervical/vaginal laceration
• Fever > 38°C after first 24 hr → infection workup
• Severe headache, BP > 140/90 → late-onset preeclampsia
• Unilateral calf swelling, redness, pain → DVT workup
• SOB, chest pain → PE workup (medical emergency)
• Foul lochia + abdominal pain → endometritis
• Inability to void after 6-8 hr → catheterize
• Suicidal ideation or self-harm thoughts → emergency mental health evaluation

Patient Education During Assessment

• Normal vs abnormal findings
• When to call provider after discharge
• Self-fundal massage if home use
• Lochia changes over time
• Perineal care, breast care
• Signs of postpartum depression

Maternal role attainment is the process of becoming a mother — taking on the maternal role and developing maternal identity. Reva Rubin (1961) described three classic phases of psychological adaptation in the postpartum period.

Rubin's Three Phases of Maternal Role Attainment

1. Taking-In (Days 1-2): Passive, dependent, focused on own physical recovery
2. Taking-Hold (Days 2-10): Increased autonomy, eager to learn newborn care
3. Letting-Go (1+ weeks): Integration of newborn into family unit, redefinition of self

While Rubin's original timeline has been updated (modern practice notes phases overlap and progress faster with shorter hospital stays), the framework remains useful for understanding postpartum adaptation.

Taking-In Phase (Days 1-2)

• Maternal focus: her own needs (food, fluid, rest, physical recovery)
• Passive, dependent on others for care
• Talks about birth experience repeatedly (processing)
• Needs nurturing and reassurance
• Limited interest in newborn care initially
• Difficulty integrating new information — teaching is poorly retained
• Tearfulness may occur
• Sleep needs are high

Taking-Hold Phase (Days 2-10)

• Maternal focus: increasing focus on newborn and learning to mother
• Becomes more independent
• Eager to learn newborn care
• Optimal time for teaching — high motivation, better retention
• Concerned with body image, bladder/bowel function
• May feel inadequate or anxious about caring for newborn
• Often coincides with "baby blues" (50-80% incidence)
• Mother regains energy and engagement

Letting-Go Phase (1+ weeks)

• Maternal focus: family unit and accepting newborn as separate individual
• Integration of newborn into family
• Reestablishment of relationships (partner, other children)
• Acceptance of changes in lifestyle and self-image
• Letting go of expectations about birth and motherhood
• Adapting to reality of motherhood
• Resumption of pre-pregnancy activities (modified)

Healthy Attachment Behaviors

• En face position: face-to-face eye contact (~8 inches distance)
• Calling newborn by name
• Parentese: high-pitched, slow, melodic speech
• Progressive touch: fingertip → palmar → enfolding
• Identifying specific features ("She has my nose")
• Skin-to-skin contact
• Responding to newborn cues
• Engrossment (in partner): intense preoccupation with newborn

Warning Signs of Impaired Attachment

• Negative comments about newborn
• Avoiding eye contact or refusing to hold
• Inappropriate handling (rough, distant)
• Lack of interest in newborn's care
• Using generic terms only ("it," "the baby" — never name)
• Refusing to name newborn
• Crying, withdrawal, or hostility

Nursing Interventions for Taking-In Phase:

• Provide nurturing care and meet basic needs (food, fluid, rest, comfort)
• Allow mother to talk about birth experience — validate feelings
• Avoid extensive teaching during this phase
• Provide pain management for postpartum discomfort
• Encourage skin-to-skin contact even if mother is tired
• Support partner's involvement in newborn care
• Brief, simple education only
• Don't be alarmed by passivity or self-focus — this is normal

Nursing Interventions for Taking-Hold Phase

• Prime time for teaching:
  • Newborn care: diapering, bathing, cord care, swaddling, soothing
  • Feeding (breastfeeding latch, formula prep, burping)
  • Recognizing newborn cues
  • Self-care (perineal care, breast care, lochia, activity)
  • Warning signs for self and newborn
  • Postpartum depression awareness
• Build maternal confidence — praise efforts
• Allow mother to provide care while you observe
• Refer to lactation consultant if needed
• Address body image and bladder/bowel concerns
• Provide written materials for later reference
• Screen for postpartum blues vs depression

Nursing Interventions for Letting-Go Phase

• Encourage involvement of partner and family
• Discuss sibling adaptation
• Address concerns about returning to work
• Refer to support groups, lactation support, mommy groups
• Postpartum depression screening at 6-week visit
• Resume sexual activity counseling
• Contraception planning
• Discuss self-care and rest

Promoting Attachment

• Facilitate immediate skin-to-skin contact at delivery (golden hour)
• Rooming-in
• Encourage breastfeeding
• Support family-centered care (visitors as desired)
• Identify and support cultural practices
• Document attachment behaviors
• Identify risk factors for impaired attachment (PPD, abuse history, unwanted pregnancy)

Risk Factors for Delayed/Impaired Role Attainment

• Difficult or traumatic birth experience
• Newborn complications (NICU admission, prematurity)
• Postpartum depression
• Lack of social support
• Adolescent mother
• Unwanted/unplanned pregnancy
• Substance abuse
• History of childhood trauma
• Domestic violence
• Major life stressors (financial, housing)

Motor vehicle crashes are the leading cause of death in children > 1 year old. Proper car seat installation and use reduce death by 71% for infants. Most parents install car seats incorrectly without instruction. Car seat education and installation verification are essential before hospital discharge.

AAP Recommendations (2018 Update)

• Rear-facing until at least age 2 OR maximum weight/height for the seat (whichever comes first)
• Forward-facing with harness after rear-facing limit, until reaches harness limit (40-65 lb)
• Booster seat until adult seat belt fits properly (typically age 8-12)
• Back seat until at least age 13

Types of Car Seats for Newborns

• Infant-only seats (rear-facing only):
  • Designed for newborns up to 22-35 lb (varies)
  • Carrier-style with detachable base
  • Most common for newborns
• Convertible seats:
  • Can be used rear-facing then forward-facing
  • Higher weight limits (rear: 35-50 lb)
  • Stay in the vehicle
• All-in-one seats: Rear-facing → forward-facing → booster

Critical Installation Principles:

Position

• ALWAYS rear-facing for newborns
• NEVER place rear-facing seat in front seat with active airbag — fatal head injury risk if airbag deploys
• Center rear seat is statistically safest position
• Side window seat acceptable if center can't accommodate

Recline Angle

• 30-45° recline angle for newborns (head shouldn't slump forward — airway compromise)
• Use built-in level indicators
• May need pool noodle or rolled towel under base to achieve angle (only if manufacturer permits)

Installation Tightness

• Use either LATCH (Lower Anchors and Tethers for Children) system OR vehicle seat belt — NEVER both
• LATCH weight limit varies (typically 65 lb for combined weight of child + seat)
• Car seat should not move more than 1 inch front-to-back or side-to-side at the belt path
• Press knee firmly into seat while tightening to compress and secure

Harness Position

• Rear-facing: harness straps at or BELOW shoulders
• Forward-facing: harness at or ABOVE shoulders
• Chest clip AT ARMPIT LEVEL (over the collarbones, level with armpits)
• Harness should be snug — cannot pinch a fold of webbing at the shoulder
• No twists in the harness

What NOT to Use

• NO bulky coats or blankets BEHIND/UNDER the harness — compresses in crash, harness too loose
• NO aftermarket products not approved by manufacturer: mirrors, head supports, harness covers, snuggle pads, swaddle wraps for car seat
• NO sleep positioners or wedges
• Approved: head support that comes WITH the seat

Special Considerations for Newborns

• Verify weight is appropriate for seat (most seats > 4 lb minimum; some have lower limits)
• Preterm/low birth weight infants: Car Seat Challenge required before discharge

Before Discharge Education:

• Verify family has car seat available
• Confirm understanding of:
  • Rear-facing requirement
  • Back seat placement
  • NO airbag rule
  • Harness adjustment
  • Chest clip position
• Demonstrate proper installation if possible
• Provide written materials
• Refer to certified Child Passenger Safety Technician (CPST) for installation check
• Discuss: NHTSA inspection stations are free

Car Seat Challenge (for Preterm/LBW Infants)

• Required before discharge for: infants < 37 weeks gestation, < 2.5 kg birth weight, low APGAR, or known cardiopulmonary issues
• Procedure: place infant in their own car seat at the recline angle that will be used
• Monitor with pulse oximetry × 90-120 minutes (or duration of typical car trip)
• Fail criteria:
  • Desaturation < 90% (or per institutional protocol)
  • Apnea > 20 seconds
  • Bradycardia < 80 bpm
• If fails: car bed (lie-flat) used until follow-up assessment

Common Parent Questions

• "Can I use a coat in cold weather?" Buckle baby in with thin clothing first, THEN place blanket over harness
• "How long can the baby be in the car seat?" Limit to 2 hours when possible; take breaks for tummy time
• "What if my baby falls asleep in the car seat?" Safe in the car; transfer to crib for sleep at home — car seat is NOT a sleep surface
• "When can I face forward?" Rear-facing until at least age 2 (longer is safer)
• "What about used car seats?" Only safe if: no crash history, no expiration date passed (typically 6 years from manufacture), no recalls, all parts present, instructions available

Resources for Parents

• NHTSA (nhtsa.gov) — free car seat inspection locations
• Local fire/police stations often have CPSTs
• AAP HealthyChildren.org car seat finder
• SafeKids.org
• Manufacturer's instruction manual and vehicle owner's manual

Reporting and Replacement

• Replace car seat after ANY crash (per NHTSA)
• Check for recalls (registered with manufacturer)
• Verify expiration date (typically 6 years)

The Five P's are factors affecting the labor process:

1. Powers — uterine contractions (primary) and maternal pushing efforts (secondary in second stage)
2. Passenger — the fetus: size, lie, presentation, position, attitude
3. Passage — the pelvis (true and false), pelvic outlet, soft tissues
4. Position — maternal positioning during labor
5. Psyche/Psychological response — maternal anxiety, fear, coping, support

1. Powers:

• Primary: involuntary uterine contractions
• Frequency, duration, intensity, resting tone
• Effective contractions cause cervical effacement and dilation
• Secondary: maternal pushing in second stage

2. Passenger:

• Lie: longitudinal (normal), transverse (abnormal), oblique
• Presentation: cephalic (vertex normal; brow/face abnormal), breech (frank, complete, footling), shoulder
• Position: relationship of presenting part to maternal pelvis (e.g., LOA, ROA, LOP)
• Attitude: degree of flexion (full flexion = vertex, optimal)
• Station: level of presenting part relative to ischial spines (-5 to +5)
• Size: macrosomia complicates

3. Passage:

• True pelvis: inlet, midpelvis, outlet
• Pelvis types: gynecoid (most favorable), android (heart-shaped, poor), anthropoid (oval), platypelloid (flat, very narrow)
• Soft tissues: cervix, vagina, perineum (elasticity)
• CPD (cephalopelvic disproportion) can prevent vaginal birth

4. Position (maternal):

• Upright positions (walking, standing, squatting): use gravity, may shorten labor
• Hands and knees: helps OP rotation
• Side-lying: rest, can help slow labor
• Supine: NOT ideal (supine hypotension, slower)
• Encouraged to change positions frequently

5. Psyche:

• Anxiety, fear → ↑ catecholamines → ↓ contractions, ↓ progress
• Support persons, doula, environment, prior experiences
• Cultural beliefs
• Coping mechanisms
• Confidence in ability to birth

All five P's must work in harmony for normal labor progress. Imbalance in any can cause dystocia (dysfunctional labor).

Powers depend on:

• Uterine integrity, gestational age, hormones (oxytocin, prostaglandins)
• Position, hydration, fatigue

Passenger depends on:

• Fetal head plasticity (molding allows passage)
• Diameters of presenting part
• Optimal: vertex, full flexion, occiput anterior

Passage depends on:

• Bony pelvis: largely fixed, but soft tissue gives
• Pelvic types affect labor mechanics
• Soft tissues: estrogen, relaxin soften connective tissue

Position effects:

• Upright: gravity assists descent, larger pelvic diameter
• Pelvic openings 30% larger in squatting/hands and knees

Psyche effects:

• Fight-or-flight (stress) → catecholamines inhibit oxytocin and contractions
• Relaxation → endorphins, oxytocin support labor

Assess each P:

• Powers: monitor contractions (frequency, duration, intensity)
• Passenger: Leopold maneuvers, ultrasound; cervical exam for position/station
• Passage: history of prior births, pelvic assessment, fetal size estimate
• Position: encourage frequent changes, ambulation
• Psyche: continuous emotional support, doula/family involvement

Optimize each P:

• Powers: Hydration, position changes, oxytocin if augmentation needed; rest if exhausted
• Passenger: Encourage optimal positioning (hands and knees for OP); ECV for breech; cesarean for malpresentation
• Passage: Position changes to maximize pelvic outlet; avoid lithotomy
• Position: Walking, squatting, hands and knees, peanut ball, side-lying
• Psyche: Continuous support, breathing techniques, environment (quiet, dim lights), pain management, education and reassurance

Documentation:

• Contraction pattern
• Cervical changes
• Fetal position, station
• Maternal positioning
• Coping, support

When P's are not working:

• Identify which P
• Targeted intervention
• Sometimes intervention needed (augmentation, position change, cesarean)

First Stage: onset of regular contractions → full cervical dilation (10 cm)

• Latent phase (0-6 cm): contractions mild to moderate, less frequent; many women can sleep, eat lightly, ambulate; can last hours-days for primips
• Active phase (6-10 cm): contractions stronger, more frequent (every 2-3 min); rapid dilation; intense; ~1-2 cm/hour
• Transition (8-10 cm): peak intensity; brief but intense; may feel "out of control"

Second Stage: full dilation → birth of baby

• Pushing stage
• Primigravida: up to 2-3 hours (longer with epidural)
• Multigravida: minutes to 1 hour
• Cardinal movements: engagement, descent, flexion, internal rotation, extension, external rotation, expulsion

Third Stage: birth of baby → delivery of placenta

• 5-30 minutes typically
• Active management with oxytocin
• Signs of placental separation: lengthening cord, gush of blood, uterine contraction, uterus becomes globular

Fourth Stage: 1-4 hours postpartum

• Recovery stage
• Hemodynamic stabilization
• Bonding, breastfeeding initiation
• Watch for hemorrhage

Why staged? Each stage has distinct physiologic events, risks, and nursing care priorities.

First stage:

• Cervical effacement and dilation occur
• Effacement (thinning) is %
• Dilation (opening) is in cm (0-10)
• Primip: effacement before dilation
• Multip: simultaneous

Second stage:

• Ferguson reflex (oxytocin surge with stretching of vagina)
• Cardinal movements: passive descent through pelvis
• Crowning: largest diameter of head emerges

Third stage:

• Uterine contractions continue → placental shearing from uterine wall
• Uterotonic effect of oxytocin
• Schultz mechanism (shiny side first) vs Duncan (dirty/maternal side first)

Fourth stage:

• Uterine contraction prevents hemorrhage
• Cardiovascular shift: ↑ cardiac output (auto-transfusion from uterus)
• Risk of: PPH, hematomas, eclampsia

First stage nursing care:

• Vital signs Q1h (active labor) or Q4h (latent)
• Fetal monitoring (continuous or intermittent based on risk)
• Contraction assessment
• Cervical exams (limit to minimize infection)
• Position changes, ambulation in latent/early active
• Pain management — non-pharm and pharm
• Hydration (IV or oral)
• Empty bladder Q2h
• Emotional support, education

Second stage:

• Vital signs Q15-30 minutes
• FHR Q15 minutes (with each push)
• Coach pushing (open vs closed glottis based on preference)
• Allow descent (delayed pushing OK)
• Position changes (squat, hands and knees, side-lying)
• Encourage rest between pushes
• Prepare for delivery
• Time second stage

Third stage:

• Watch for signs of separation
• Avoid traction until separation
• Active management (oxytocin)
• Examine placenta for completeness
• Document time of placental delivery
• Skin-to-skin with mother

Fourth stage:

• Vital signs Q15 min × 1 hour, then Q30 min × 1, then Q1h
• Fundal checks (firm, midline, at umbilicus level)
• Lochia assessment (amount, color)
• Perineum assessment
• Bladder (encourage void, watch for retention)
• Bonding facilitation
• Breastfeeding initiation
• Pain management
• Watch for hemorrhage

True labor:

• Regular contractions that become progressively closer, longer, stronger
• Cause cervical change (effacement, dilation)
• Pain typically starts in back, radiates to abdomen
• Walking increases or doesn't change intensity
• Not relieved by hydration, rest, or position changes
• Bloody show may be present
• Membranes may rupture

False labor (Braxton Hicks):

• Irregular contractions, don't progress
• No cervical change
• Pain in abdomen only (not back)
• Walking, rest, or hydration often relieves contractions
• Position changes relieve
• No bloody show typically
• Common in late pregnancy

Other signs that labor is starting:

• Lightening (baby drops)
• Loss of mucus plug (bloody show)
• Spontaneous rupture of membranes (water breaking)
• Energy burst (nesting)
• Backache, pelvic pressure
• Diarrhea (some)
• Cervical changes on exam

Physiology:

• True labor: oxytocin surge, increased prostaglandins, uterine sensitivity → coordinated effective contractions
• False labor: uterine activity without sufficient prostaglandins/oxytocin → uncoordinated, ineffective

5-1-1 rule:

• Contractions every 5 minutes
• Lasting 1 minute each
• For 1 hour
• → Time to go to hospital (low-risk multips: 4-1-1)

Important distinction:

• Only cervical change definitively confirms true labor
• Contraction pattern is suggestive
• Some women have prodromal labor (irregular but causing some changes) — frustrating

SROM (spontaneous rupture of membranes):

• Gush or trickle of clear fluid
• Cannot be controlled (vs urine)
• Watch for: color (greenish = meconium, concerning), amount, time of rupture, contractions
• Bring to hospital even if no contractions

Education on signs of labor:

• Prenatal classes
• Discuss 5-1-1 rule for nullipara
• 4-1-1 for multipara
• Bloody show OK; trickle of blood OK
• Significant bleeding → ER immediately
• SROM: come to hospital

Assessment at admission:

• Contraction pattern (frequency, duration, intensity)
• Cervical exam (dilation, effacement, station, position)
• Compare to prior exam if available
• Determine: true labor, prodromal, or false labor

If false labor:

• Reassurance
• Hydration
• Walking
• Discharge to home with instructions
• Return precautions: bleeding, ROM, regular intense contractions, decreased fetal movement, severe headache/visual changes (preeclampsia)

If true labor:

• Admit
• Initiate labor care
• Continuous fetal monitoring as indicated
• Family support

Watch for and report (during pregnancy late 3rd tri):

• Regular contractions in true labor pattern
• SROM
• Bleeding
• Decreased fetal movement
• Severe headache, visual changes, RUQ pain (preeclampsia)
• Persistent vomiting

National Institute of Child Health and Human Development (NICHD) three-tier system for interpreting fetal heart rate (FHR) tracings:

Category I (Normal):

• Baseline 110-160 bpm
• Moderate variability (6-25 bpm)
• Accelerations: present or absent
• Late or variable decelerations ABSENT
• Early decelerations: present or absent
• Reassuring — normal acid-base status; continue routine care

Category II (Indeterminate):

• Everything NOT Category I or III
• Most tracings fall here
• Variable: absent or minimal variability with no decelerations; absent variability with recurrent variable or late decelerations; tachycardia; bradycardia without absent variability
• Recurrent variable or late decelerations with moderate variability
• Not predictive of abnormal fetal acid-base status, but warrants evaluation, continued surveillance, intrauterine resuscitation

Category III (Abnormal):

• Absent variability AND any of:
• - Recurrent late decelerations
• - Recurrent variable decelerations
• - Bradycardia
• OR sinusoidal pattern
• Predictive of abnormal acid-base status — requires prompt evaluation and intervention; may require immediate delivery

Components of FHR assessment:

• Baseline rate: 110-160 bpm (over 10 min, excluding accels/decels)
• Variability: beat-to-beat fluctuations
• - Absent: undetectable
• - Minimal: ≤ 5 bpm
• - Moderate: 6-25 bpm (NORMAL — best indicator of fetal well-being)
• - Marked: > 25 bpm
• Accelerations: abrupt ↑ > 15 bpm above baseline, lasting ≥ 15 seconds (10 bpm/10 sec if < 32 wks); GOOD SIGN
• Decelerations:
• - Early: gradual onset, mirrors contraction (head compression — benign)
• - Variable: abrupt onset, V/U/W shape (cord compression)
• - Late: gradual, AFTER contraction peak (uteroplacental insufficiency — concerning)
• - Prolonged: ≥ 2 minutes but < 10 minutes
• - Sinusoidal: smooth sine-wave (severe fetal anemia — concerning)

Why three-tier:

• Provides framework for communication and decision-making
• Most tracings (~80%) are Category II — requires clinical judgment
• Category III rare but indicates urgent intervention needed

VEAL CHOP mnemonic:

• Variable decels = Cord compression
• Early decels = Head compression
• Accelerations = OK (well-oxygenated)
• Late decels = Placental insufficiency

Category I:

• Continue routine care
• Documentation
• Reassure mother

Category II:

• Continued surveillance, more frequent monitoring
• Intrauterine resuscitation:
• - Position change (left side-lying, then right if no improvement)
• - O2 by face mask 10 L/min
• - IV fluid bolus (LR 500 mL)
• - Stop oxytocin if running
• - Correct hypotension (epidural-related)
• - Treat hyperstimulation (terbutaline)
• - Internal monitoring (FSE, IUPC) if external inadequate
• Notify provider
• Reassess after interventions
• If not improving → may need Category III workup

Category III:

• Notify provider immediately
• Intrauterine resuscitation (as above)
• Prepare for emergent delivery (likely cesarean)
• OR ready
• Pediatric/neonatal team to attend
• Document interventions and response
• Communicate clearly with team
• Family support

Documentation:

• Document FHR strip every 15-30 min in active labor
• Note: baseline, variability, accelerations, decelerations
• Tier/category
• Interventions and response
• Provider notifications

Communication:

• SBAR format
• Provider must see strip
• Closed-loop communication
• Document conversations

First stage: onset of regular contractions to full cervical dilation (10 cm). Subdivided:

Latent phase (0-6 cm):

• Contractions: mild to moderate, every 5-30 min, lasting 30-45 sec
• Cervical change slow
• Patient often able to talk, walk, eat lightly
• Duration: 6-8+ hours primip; 4-5 hours multip

Active phase (6-10 cm):

• Contractions: stronger, every 2-3 min, lasting 60-90 sec
• Dilation 1-1.5 cm/hour (primip); faster (multip)
• More intense pain

Transition phase (8-10 cm):

• Contractions: every 2-3 min, lasting 60-90 sec, intense
• Bloody show
• Possible vomiting, trembling
• Often feels "out of control"
• Brief but intense

Key assessments:

• Vital signs
• Contraction pattern (frequency, duration, intensity)
• Fetal heart rate
• Cervical exam
• Pain assessment
• Coping, support

Goals of first stage:

• Effacement and dilation (mechanical changes of cervix)
• Fetal descent begins
• Establish coping and support patterns
• Manage pain
• Monitor mother and fetus safely
• Identify complications early

Cervical changes:

• Effacement: cervix thins from approximately 2 cm thick to paper-thin
• Measured 0-100%
• Dilation: cervix opens from 0 cm to 10 cm
• Primip: effacement happens before dilation; multip: simultaneous

Powers (contractions) characteristics:

• Frequency: from start of one to start of next
• Duration: from start to end of one contraction
• Intensity: mild, moderate, strong (palpation or IUPC in mmHg)
• Resting tone: relaxed uterus between contractions

Hydration and nutrition:

• Latent: clear liquids and light foods often OK
• Active: typically clear liquids, ice chips
• IV fluids if NPO or for hydration

Vital signs:

• BP, HR, RR Q1h in active labor; Q4h latent
• Temperature Q4h (Q2h after ROM)

Contraction assessment:

• Q30 min in active labor
• Q1h latent
• External tocodynamometer or palpation
• IUPC for accurate intensity if needed

Fetal monitoring:

• Low-risk: intermittent auscultation Q30 min active labor; Q1h latent
• High-risk: continuous external or internal monitoring
• Document Category I, II, or III
• Note baseline, variability, accelerations, decelerations

Cervical exam:

• Limit to minimize infection (especially after ROM)
• Performed at admission, periodically with progress, before pain medication
• Document: dilation, effacement, station, position, membranes intact or ruptured

Comfort measures:

• Position changes Q30 min (walking, side-lying, hands and knees, ball)
• Breathing techniques
• Massage, counter-pressure
• Warm compresses, ice
• Hydrotherapy (shower, tub)
• Music, dim lights
• Aromatherapy
• Continuous labor support (doula, family)

Pain management:

• Non-pharm first
• Pharm: IV opioids (nubain, butorphanol — note opioid timing for newborn respiratory depression), epidural, spinal

Hydration:

• Encourage clear liquids, ice chips
• IV LR or NS
• Empty bladder Q2h

Watch for:

• Fetal distress (Category III)
• Hyperstimulation
• Bleeding
• Maternal fever
• Hypertension
• Inadequate progress (consider dystocia)
• ROM (note time, color, amount)

Family-centered care:

• Involve support person
• Continuous emotional support
• Updates on progress

Second stage: full cervical dilation (10 cm) → birth of baby. Pushing stage.

Duration:

• Primigravida without epidural: up to 2 hours (3 hours with epidural)
• Multigravida without epidural: up to 1 hour (2 hours with epidural)
• Beyond these → arrest of descent

Phases:

• Latent (laboring down): 10 cm but no urge to push; fetus descending passively; allowed with epidural
• Active pushing: ferguson reflex, Valsalva pushing
• Birth: crowning to expulsion

Cardinal movements:

1. Engagement (largest diameter through inlet)
2. Descent
3. Flexion
4. Internal rotation (occiput to anterior)
5. Extension (head delivers)
6. External rotation (restitution + shoulders rotate)
7. Expulsion

Signs of imminent birth:

• Bulging perineum
• Crowning (presenting part visible at perineum)
• Strong urge to push
• Bloody show ↑
• "Burning" or "stretching" sensation

Ferguson reflex:

• Stretching of vagina by presenting part → oxytocin release → stronger contractions and urge to push

Pushing technique:

• Open-glottis (physiological): push when urge, brief efforts, breathe through contractions — preferred
• Closed-glottis (directed/Valsalva): 10-second sustained pushes — traditional, but may cause maternal fatigue and reduce fetal oxygenation
• Evidence supports patient-led, open-glottis pushing

Why delayed pushing OK:

• Allows passive descent through cardinal movements
• Reduces maternal exhaustion
• Especially helpful with epidural

Crowning:

• Head no longer recedes between contractions
• Largest diameter of head emerging
• Critical moment — controlled delivery prevents lacerations

Maternal physiologic changes:

• ↑ BP, ↑ HR with pushing
• Hyperventilation
• Possible vomiting
• Trembling

Vital signs:

• BP Q5-15 min
• HR Q5-15 min
• Continuous fetal monitoring (Q5-15 min with each push)

Coaching pushing:

• Encourage spontaneous pushing first
• If directed pushing needed: deep breath, push with contraction
• 3 pushes per contraction typically
• Rest between contractions
• Allow downward grunting (physiological)

Positioning:

• Variety of positions — patient preference
• Side-lying, semi-Fowler, hands and knees, squatting, lithotomy
• Upright positions may shorten second stage
• Change positions if not progressing
• Avoid lithotomy if possible (reduces pelvic outlet)

Perineal care:

• Warm compresses to perineum (may reduce tears)
• Gentle massage if desired
• Support perineum during crowning to control delivery

Comfort:

• Cool cloth to forehead
• Ice chips
• Encouragement
• Mirror so patient can see (some)

Watch for fetal distress:

• Variable decels common (cord compression)
• Late decels concerning (placental insufficiency)
• Continuous monitoring

Prepare for delivery:

• Sterile delivery field
• Resuscitation equipment ready
• Identification bands
• Skin-to-skin plan
• Time of birth

Delivery of baby:

• Provider controls head emergence (slow)
• Suction nose, mouth if needed
• Check for cord around neck (nuchal cord)
• Anterior shoulder, then posterior, then body
• Place baby on mother (skin-to-skin)
• Dry, stimulate, suction PRN
• Clamp cord (delayed if possible — 1-3 minutes)
• Apgar score at 1 and 5 minutes

Watch for arrest of descent:

• No descent in 1 hour active pushing
• Notify provider
• Position changes
• May need vacuum, forceps, or cesarean

Third stage: birth of baby → delivery of placenta. Usually 5-30 minutes; concerning if > 30 min.

Mechanisms of placental separation:

• Schultze mechanism (most common): shiny side (fetal) presents first, looks like inverted umbrella
• Duncan mechanism: dirty/maternal side presents first, irregular surface

Signs of placental separation:

• Uterus rises in abdomen
• Uterus becomes globular (round, firm)
• Sudden gush of blood
• Cord lengthens (lengthens at vulva)
• Patient may feel urge to push again

Active management of third stage (recommended for all):

• Oxytocin administration with anterior shoulder or after birth
• Controlled cord traction (with countertraction on uterus)
• Uterine massage after placental delivery
• Reduces postpartum hemorrhage

Physiology:

• Uterine contractions continue after birth
• Placental site shrinks → placenta separates from uterine wall
• Living ligature (uterine muscle fibers) clamps blood vessels → controls bleeding
• Oxytocin (endogenous or exogenous) supports contraction

Why active management:

• Reduces postpartum hemorrhage risk by 50%
• Standard of care
• Shortens third stage

Placenta examination importance:

• Detect retained fragments (cause of late PPH)
• Check completeness (intact cotyledons, intact membranes)
• Number of vessels in cord (normally 2 arteries, 1 vein — single artery may suggest anomalies)
• Note any abnormalities (calcifications, infarcts, abnormal insertion)

Bleeding considerations:

• Average blood loss: 500 mL vaginal birth, 1000 mL cesarean
• PPH: > 500 mL vaginal or > 1000 mL cesarean (or any amount causing hemodynamic compromise)
• Most common cause of PPH: uterine atony

Active management protocol:

• Administer oxytocin (10 units IM or IV in fluid bag) at delivery of anterior shoulder or immediately after birth
• Controlled cord traction with countertraction (provider responsibility — guard uterus)
• Don't pull on cord without contraction
• Fundal massage after placental delivery

Watch for separation signs:

• Uterus rises and globular
• Cord lengthens
• Gush of blood
• Time placental delivery (concerning if > 30 min)

After placental delivery:

• Inspect placenta for completeness
• - Cotyledons intact?
• - Membranes intact?
• - Vessels: 2 arteries, 1 vein
• - Abnormalities (calcifications, infarcts)
• - Insertion (central, marginal, velamentous)
• Document findings

Examine for lacerations:

• Perineum (1st-4th degree)
• Vagina, sidewalls
• Cervix (with bleeding despite firm fundus)
• Periurethral

Maternal status:

• Vital signs Q15 min
• Bleeding assessment
• Fundal massage
• Pain management for repair

Newborn care:

• Skin-to-skin contact
• Initial assessment
• Vitamin K, erythromycin eye prophylaxis (delay 1 hour for bonding/breastfeeding)
• Apgar at 1 and 5 minutes
• Identification bands matched

Breastfeeding initiation:

• Within first hour optimal
• Skin-to-skin facilitates
• Hand expression to colostrum

If retained placenta:

• Wait up to 30 min if not bleeding
• Try emptying bladder, breastfeeding (oxytocin)
• If continued: manual removal under anesthesia
• Watch for PPH

Documentation:

• Time of placental delivery
• Mechanism (Schultze or Duncan)
• Placenta complete or not
• Cord vessels
• Estimated blood loss
• Medications given
• Lacerations

The initial prenatal visit (8-12 weeks gestation, ideally) establishes baseline data, identifies risk factors, and sets up the plan of care.

Components:

1. Detailed history:

• Demographics: age, ethnicity, occupation
• Menstrual history: menarche, cycle pattern, LMP (for dating)
• Obstetric history:
• - GTPAL: Gravida (total pregnancies), Term (≥ 37 weeks), Preterm (20-36+6), Abortions/losses (< 20 weeks), Living children
• - Prior pregnancy outcomes (vaginal/cesarean, complications)
• - Postpartum complications
• - Infant outcomes
• Gynecologic history: STIs, infections, surgeries, abnormal Paps
• Medical history: chronic conditions (DM, HTN, asthma, autoimmune, cardiac), surgeries, hospitalizations
• Family history: chronic disease, genetic disorders, pregnancy outcomes
• Genetic screening: ethnicity-specific risks (sickle cell, Tay-Sachs, thalassemia)
• Medications, allergies
• Substance use: tobacco, alcohol, drugs (illicit and prescription)
• Social: housing, finances, support, IPV screening, mental health
• Current pregnancy: symptoms, complications, intentional/unintentional

2. Physical exam:

• Vital signs, height, weight, BMI
• Head-to-toe exam
• Breast exam (changes in pregnancy)
• Pelvic exam: speculum (cervix, vagina), bimanual
• Pelvic adequacy assessment
• Fetal heart tones (after 10-12 weeks via Doppler)

3. Labs/diagnostics (see Routine Prenatal Labs template)

4. Risk stratification:

• Low-risk vs high-risk pregnancy
• Referrals as needed (MFM, genetics)

Naegele's rule for EDD calculation:

• LMP + 7 days - 3 months + 1 year = EDD
• Example: LMP June 1, 2024 → EDD March 8, 2025
• Assumes 28-day cycle
• Ultrasound dating preferred for irregular cycles or unsure LMP

Pregnancy terminology:

• Gravida: total pregnancies including current
• Para: pregnancies that reached viability (20 weeks) regardless of outcome
• Term: ≥ 37 weeks
• Preterm: 20-36+6
• Abortions: < 20 weeks (spontaneous or elective)
• Living: number of currently living children

Why thorough history:

• Identify risk factors for complications
• Plan appropriate level of care
• Genetic counseling if indicated
• Schedule appropriate testing
• Establish baseline for comparison
• Build therapeutic relationship

Risk stratification examples:

• Low-risk: healthy, no complications
• High-risk: chronic conditions, prior complications, advanced age, substance use, multiple gestation, congenital concerns

Establishing relationship:

• Welcoming, non-judgmental approach
• Cultural sensitivity
• Privacy
• Adequate time for questions

Comprehensive history-taking:

• Use structured interview (medical, obstetric, social)
• Explore in detail; don't assume
• Document carefully
• Update at each visit

Calculate GTPAL:

• Example: Pregnant woman with 1 prior term birth, 1 preterm birth (currently living), 1 miscarriage
• G3 (current is 3rd pregnancy if counting), T1 P1 A1 L2

Confirm pregnancy:

• Urine hCG
• Serum hCG if needed
• Ultrasound for dating, viability

Assess for IPV:

• Routine screening (private, every visit)
• Safety planning
• Resources

Substance use screening:

• Routine, non-judgmental
• Tobacco, alcohol, illicit drugs, prescription misuse
• Refer for treatment

Mental health screening:

• Edinburgh Postpartum Depression Scale or PHQ-9
• Anxiety screening
• Suicidality

Establish plan of care:

• Visit schedule (monthly to 28 weeks, biweekly to 36 weeks, weekly after)
• Provider for delivery
• Birth setting
• Lab schedule
• Genetic testing offered

Education:

• Diet, exercise, weight gain
• Prenatal vitamins (with folate)
• Avoid: alcohol, tobacco, illicit drugs, certain meds, raw meat/fish, unpasteurized dairy, deli meat, high-mercury fish
• Caffeine limits (< 200 mg/day)
• Hot tubs, saunas avoided
• Travel, sex generally safe
• Warning signs to report

Schedule:

• Next visit
• Labs
• Ultrasound (dating, anatomy ~20 weeks)
• Genetic screening offered

Watch for and report:

• Vaginal bleeding
• Severe abdominal/pelvic pain
• Severe headache
• Visual disturbances
• Persistent vomiting
• Fever
• Severe edema (especially face/hands)
• Decreased fetal movement (after 28 weeks)
• ROM
• Signs of preterm labor

Naegele's rule: standard method for calculating estimated date of delivery (EDD/EDC) based on last menstrual period (LMP).

Formula:

• First day of LMP + 7 days - 3 months + 1 year = EDD

Example:

• LMP: June 1, 2024
• Add 7 days → June 8
• Subtract 3 months → March 8
• Add 1 year → March 8, 2025 = EDD

Pregnancy terms by gestational age:

• Pregnancy = 40 weeks (280 days) from LMP
• Term: 37-42 weeks
• Early term: 37-38+6/7 weeks
• Full term: 39-40+6/7 weeks
• Late term: 41+0/7 to 41+6/7
• Post-term: ≥ 42 weeks
• Preterm: 20-36+6/7
• Trimesters:
• - First: 0-12+6/7 weeks
• - Second: 13-27+6/7 weeks
• - Third: 28-40+ weeks

Assumptions in Naegele's rule:

• Regular 28-day menstrual cycle
• Ovulation at day 14
• Conception within 24 hours of ovulation

Limitations:

• Less accurate with irregular cycles
• Less accurate if patient doesn't recall LMP
• Different cycle lengths affect accuracy
• Only ~5% of women deliver on EDD

Adjustments for cycle length:

• If cycle ≠ 28 days: subtract or add days based on cycle length
• Example: 32-day cycle → add 4 days to EDD calculated by Naegele's

Ultrasound dating:

• First trimester ultrasound is most accurate for dating (especially < 14 weeks)
• Crown-rump length (CRL) accuracy ± 5-7 days
• If ultrasound discrepancy from LMP-based EDD is > 5 days in 1st trimester, ultrasound prevails
• If discrepancy > 14 days in 2nd trimester, ultrasound prevails
• If discrepancy > 21 days in 3rd trimester, ultrasound prevails

Why accurate dating matters:

• Schedule appropriate screening tests
• Genetic screening timing
• Detect IUGR vs SGA
• Detect macrosomia
• Determine prematurity
• Timing of induction
• Postdates management

Initial dating:

• Obtain LMP at first prenatal visit
• Confirm with patient — first day of last period
• Use Naegele's rule to calculate EDD
• Document menstrual history
• Order first-trimester ultrasound for dating if uncertain

Cycle considerations:

• Note typical cycle length
• Note prior pregnancies, contraception
• Adjust EDD for irregular cycles or known ovulation date

Confirming dates:

• First-trimester ultrasound for confirmation (most accurate)
• If discrepancy: usually adjust to ultrasound
• Document decision

Communication:

• Explain EDD is an estimate
• Most births are within 2 weeks of EDD (37-42 weeks)
• Only ~5% deliver exactly on EDD
• Term pregnancy is 37-42 weeks

Calculate gestational age at each visit:

• From LMP or adjusted EDD
• Document weeks + days (e.g., 28+3 weeks)
• Useful for screening test scheduling
• Useful for detecting IUGR/macrosomia

Special situations:

• IVF pregnancy: dating from transfer (most accurate)
• Conception while on contraception or breastfeeding: ultrasound essential
• No LMP: ultrasound for dating

Pregnancy signs are classified by their certainty:

Presumptive signs (subjective — felt by woman):

• Amenorrhea (missed period)
• Nausea/vomiting ("morning sickness")
• Breast tenderness, enlargement
• Fatigue
• Urinary frequency (early due to enlarging uterus pressing bladder)
• Quickening (first perception of fetal movement — 16-20 weeks)
• Food cravings, aversions

Probable signs (objective — observed by examiner):

• Goodell sign (cervical softening — 5 weeks)
• Chadwick sign (bluish-purple cervical/vaginal color — 6-8 weeks)
• Hegar sign (softening of uterine isthmus — 6-12 weeks)
• Uterine enlargement
• Positive pregnancy test (hCG in urine or serum)
• Ballottement (passive fetal movement on examination — 16-28 weeks)
• Braxton Hicks contractions
• Pigmentation: linea nigra, chloasma

Positive signs (diagnostic — fetal origin):

• Fetal heart tones heard by Doppler (10-12 weeks) or fetoscope (17-19 weeks)
• Visualization of fetus by ultrasound
• Fetal movement palpated by examiner

Why three categories:

• Presumptive signs: caused by hormonal changes; can be from other conditions (e.g., breast tenderness from PMS, amenorrhea from stress)
• Probable signs: more specific to pregnancy but can have other causes (e.g., uterine fibroids, hCG-producing tumors — molar pregnancy, ectopic, GTD)
• Positive signs: confirm pregnancy because they can only originate from fetus

hCG (human chorionic gonadotropin):

• Produced by trophoblast after implantation (8-10 days after ovulation)
• Detectable in serum days before missed period
• Detectable in urine around time of missed period
• Peaks at 9-10 weeks, then declines
• Doubles approximately every 48 hours in early pregnancy
• Used for: confirming pregnancy, ectopic monitoring, molar pregnancy detection

Differential diagnosis to consider:

• Ectopic pregnancy
• Gestational trophoblastic disease
• Pseudocyesis
• Tumors (some produce hCG)
• Other gynecologic conditions

Earliest detectable signs/tests:

• Serum hCG: 7-10 days after conception
• Urine hCG: ~14 days after conception (around missed period)
• Ultrasound: gestational sac visible at ~4.5-5 weeks transvaginally; fetal pole at ~6 weeks; cardiac activity ~6-7 weeks

Pregnancy confirmation:

• Take history (LMP, cycle, symptoms)
• Obtain pregnancy test (urine or serum hCG)
• Physical exam (note probable signs)
• Ultrasound for positive signs (visualization, cardiac activity)
• Document carefully

Patient education:

• Distinguish presumptive vs probable vs positive
• Explain why positive signs are needed
• Address any concerns about other conditions

If pregnancy desired and confirmed:

• Discuss prenatal care
• Initiate prenatal vitamins with folate
• Avoid teratogens (alcohol, tobacco, certain meds)
• Provide first prenatal visit scheduling
• Address danger signs

If pregnancy unintended:

• Non-directive counseling
• Options counseling: continue, adoption, termination
• Patient choice
• Resources for each option
• Mental health support

If positive test but ectopic/molar suspected:

• Workup: serial hCG, ultrasound
• Refer appropriately

If pregnancy test negative but signs present:

• Repeat test in 1 week (may be too early)
• Quantitative serum hCG (more sensitive)
• Consider other causes

Educate about:

• Early pregnancy symptoms (presumptive)
• When to take pregnancy test (day of missed period or later)
• How home tests work
• Importance of dating
• Establishing prenatal care

Lochia is the vaginal discharge after birth as the uterus involutes and the placental site heals. Progresses through three stages over 4-6 weeks.

Lochia Rubra (red):

• Days 1-3 postpartum
• Bright red blood with small clots (less than nickel-sized OK)
• Heaviest flow
• Composition: blood, decidua, mucus, small clots

Lochia Serosa (pink/brown):

• Days 4-10 postpartum
• Pink-brown, watery
• Decreasing amount
• Composition: serous fluid, older blood, WBCs, microorganisms

Lochia Alba (white/yellow):

• Days 10-14 to 4-6 weeks
• Yellowish-white
• Light amount
• Composition: leukocytes, mucus, epithelial cells

Volume descriptors:

• Scant: < 1 inch (2.5 cm) on pad in 1 hour
• Light/small: < 4 inches (10 cm)
• Moderate: < 6 inches (15 cm)
• Large/heavy: > 6 inches OR saturating pad in 1 hour

Physiology:

• After placental delivery, exposed uterine vessels close off via uterine contraction (living ligature)
• Lochia is the result of healing of placental site
• Uterine involution: rapid decrease in uterine size
• Endometrial regeneration occurs (3 weeks for placental site; 6 weeks for rest)

Why three stages:

• Reflects progressive healing
• Color and amount changes indicate normal involution
• Deviations suggest complications (infection, hemorrhage)

Abnormal findings:

• Heavy bleeding or large clots (early postpartum hemorrhage)
• Persistent rubra beyond 3-4 days (subinvolution, retained fragments)
• Return to rubra after progressed to serosa (subinvolution, infection)
• Foul-smelling lochia (endometritis)
• Excessive amount, saturating > 1 pad/hour (hemorrhage)
• Continued bleeding after expected duration

Influencing factors:

• Breastfeeding: ↑ oxytocin → ↑ uterine contraction → less bleeding
• Activity: brief increase with ambulation, position changes normal
• Position: ↑ flow when standing up after lying down (pooled blood)
• Cesarean: slightly less lochia (some removed surgically)

Routine assessment (BUBBLE-HE):

• Assess lochia at every postpartum check
• Inspect pad: color, amount, odor, clots
• Note time of last pad change (gauge rate of bleeding)
• Document quantitatively when possible
• Increasing flow when getting up may indicate hemorrhage

Fundal assessment with lochia:

• Position: have woman empty bladder first
• Supine, knees flexed
• Palpate fundus: firmness (firm = good), level (at umbilicus level immediately postpartum; descends 1 fingerbreadth/day), midline (vs deviated)
• Massage if boggy
• Watch lochia during massage

Watch for warning signs:

• Saturating pad < 1 hour
• Passing large clots (> egg-sized or persistent grape-sized)
• Foul odor
• Persistent bright red blood after expected progression
• Return to rubra after serosa
• Continued lochia past 6 weeks
• Fever, chills, tachycardia (infection)
• Boggy fundus

Educate patient:

• Normal progression of lochia stages
• What's normal vs abnormal
• Hygiene: change pads regularly, peri bottle after voiding
• Wash hands
• No tampons (infection risk)
• Report excessive bleeding, foul odor, clots, fever
• Continued flow up to 6 weeks normal
• Increased flow with standing, breastfeeding (oxytocin) is normal
• Resume periods 6-8 weeks postpartum if not breastfeeding; longer if breastfeeding

Documentation:

• Color, amount, odor
• Number of pads used
• Time intervals
• Trends over shift

Signs and symptoms that require immediate evaluation during pregnancy. All pregnant women should be educated on these from the first prenatal visit.

By trimester (some common to all):

First trimester:

• Severe abdominal/pelvic pain (ectopic, miscarriage)
• Vaginal bleeding (miscarriage, ectopic)
• Severe nausea/vomiting unable to keep fluids (hyperemesis)
• Fever > 38°C (infection)
• Dysuria, frequency (UTI)

Second trimester:

• Vaginal bleeding (placenta previa, abruption)
• Severe abdominal pain (preterm labor, abruption)
• Cervical pressure, low backache (preterm labor)
• Decreased fetal movement after quickening
• Persistent vomiting
• Visual disturbances, severe headache (preeclampsia)
• Severe edema, especially face/hands
• Fever, signs of infection

Third trimester:

• Vaginal bleeding (always concerning)
• Regular contractions before 37 weeks (preterm labor)
• Rupture of membranes (PROM)
• Decreased fetal movement (kick counts < 10 in 2 hours)
• Severe headache, visual changes, RUQ pain (severe preeclampsia)
• Sudden severe edema
• Sudden weight gain (3+ lbs/week)
• Persistent abdominal pain
• Decreased urine output
• Itching especially palms/soles (cholestasis)
• Signs of true labor at term

Why early recognition matters:

• Many pregnancy complications progress rapidly
• Early intervention improves outcomes
• Some conditions (preeclampsia, abruption) can be life-threatening within hours
• Reduces maternal and fetal mortality

Key emergencies and their signs:

Ectopic pregnancy:

• Severe unilateral lower abdominal pain
• Vaginal bleeding (often light)
• Shoulder pain (referred from blood irritating diaphragm)
• Signs of shock
• Positive pregnancy test

Placental abruption:

• Vaginal bleeding (may be concealed)
• Severe constant abdominal pain
• Rigid, board-like abdomen
• Frequent contractions
• Fetal distress

Placenta previa:

• Painless bright red bleeding
• Usually no contractions

Preeclampsia/eclampsia:

• BP ≥ 140/90 after 20 weeks
• Severe headache
• Visual disturbances (blurring, scotoma, photophobia)
• RUQ or epigastric pain
• Decreased urine output
• Severe edema
• Hyperreflexia, clonus
• Seizure = eclampsia

Preterm labor:

• Regular contractions before 37 weeks
• Low backache
• Pelvic pressure
• Vaginal discharge changes
• Cervical change

PROM:

• Gush or trickle of clear fluid
• Continuous
• Cannot be controlled (vs urine)

Education at every prenatal visit:

• Review signs appropriate to gestational age
• Provide written instructions
• Emergency contact information
• "What to do" plan
• Repeat in late pregnancy

When to go where:

• Office hours: call provider for guidance
• After hours: on-call provider or L&D
• Emergency: severe bleeding, severe pain, suspected ROM, seizure → 911 or ER

Specific instructions:

• Decreased fetal movement: lie down, focused count, drink cold liquid, if < 10 movements in 2 hours → L&D
• SROM: come to L&D, don't put anything in vagina
• Contractions in true labor pattern: 5-1-1 (every 5 min, 1 min long, for 1 hour)
• Severe headache: dim lights, rest, take acetaminophen; if not relieved or with visual changes → call provider/ER
• RUQ pain: call provider immediately

Triage:

• Assess vital signs
• Fetal heart rate
• Symptoms in detail
• Risk factors
• Determine acuity

Document and report:

• Patient assessment
• Vital signs
• Fetal status
• Provider notification
• Interventions and response

Empower patient:

• Trust her instincts
• Don't dismiss concerns
• "When in doubt, get it checked"
• Address fears, anxiety

Comprehensive education for the breastfeeding postpartum client at discharge. Covers maternal recovery, breastfeeding establishment, infant care, and recognition of complications.

Maternal physical recovery:

• Lochia progression and pad use
• Perineal care (sitz baths, peri bottle)
• Cesarean wound care (if applicable)
• Pain management — acetaminophen, ibuprofen safe with breastfeeding
• Constipation prevention — fluids, fiber, stool softeners
• Hemorrhoid care
• Pelvic floor exercises (Kegels)
• Activity progression — gradual
• Sleep when baby sleeps
• Nutrition: balanced diet, adequate calories (~500 extra/day breastfeeding)
• Adequate fluids — drink to thirst, urine pale yellow

Breastfeeding establishment:

• Frequent feedings — 8-12 times/24 hours
• On demand (baby-led)
• Latch: cross-cradle, football, side-lying, cradle
• Breast care: hand expression, lanolin for soreness
• Engorgement management: frequent feeding, warm compress before, cold after
• Mastitis prevention: empty breasts, complete feeds, address blocked ducts
• Watch for: nipple cracks, severe pain, infection signs
• Lactation consultant if struggling

Newborn care:

• Feeding cues: rooting, hand-to-mouth, lip smacking, fussiness
• Wet/soiled diaper counts
• Skin-to-skin contact
• Safe sleep (back to sleep, firm surface, no soft bedding)
• Cord care (clean, dry)
• Bathing
• Temperature (axillary 97.7-99.5°F)
• Jaundice
• Umbilical and circumcision care

Emotional adaptation:

• Postpartum blues — common, transient
• Postpartum depression — warning signs
• Bonding
• Partner involvement
• Sibling adjustment

Postpartum recovery physiology:

• Uterus involutes over 6 weeks
• Lochia 4-6 weeks (typically)
• Hormonal changes affect mood
• Lactation establishes over first 2-4 weeks

Why thorough teaching:

• Reduces complications
• Improves breastfeeding success
• Identifies issues early
• Empowers mother
• Improves bonding

Breastfeeding success factors:

• Early initiation (within 1 hour)
• Skin-to-skin contact
• Frequent feedings
• Effective latch
• Adequate hydration, nutrition
• Rest
• Support system
• Avoiding bottles/pacifiers initially (nipple confusion)

Watch for and treat:

• Engorgement
• Sore/cracked nipples
• Plugged ducts
• Mastitis
• Insufficient milk concerns
• Poor latch

Pre-discharge:

• Verify breastfeeding established
• Lactation consultant if needed
• Provide written instructions
• Demonstrate care techniques
• Have mother demonstrate
• Address questions

Education topics:

Maternal:

• Lochia: rubra → serosa → alba (over 4-6 weeks)
• Pad use, no tampons, no douching
• Perineal/cesarean care
• Pain management: acetaminophen, ibuprofen, avoid aspirin (Reye's)
• Sitz baths after first 24 hours
• Adequate hydration (drink to thirst)
• Nutritional support — extra 500 calories
• Constipation prevention
• Sleep when baby sleeps
• Activity: gradual return, avoid heavy lifting
• No intercourse, tampons, douching until cleared (6 weeks)
• Family planning options
• Pelvic floor exercises

Breastfeeding:

• Frequent feedings 8-12/24 hours
• Both breasts if possible
• Latch correctly: open mouth wide, areola in mouth, lips flanged
• Recognize good latch: rhythmic suck-swallow, audible swallowing, no pain
• Burping after each side
• Hand expression, manual pumping technique
• Milk storage if pumping
• Engorgement: warm compress before, cold after
• Sore nipples: air dry, lanolin, correct latch
• Watch for: severe pain, fever, redness, hot/cold areas, hard areas → mastitis signs
• Avoid bottles/pacifiers first 4 weeks (if exclusive BF goal)
• Lactation consultant contact

Newborn:

• Feeding cues
• Diaper counts: 6+ wet, 3+ soiled by day 4 (varies)
• Sleeping back, firm surface
• Temperature taking
• Bathing, cord care
• Holding, swaddling
• Signs of illness: fever > 38°C, poor feeding, lethargy, color changes
• Pediatrician follow-up 2-3 days after discharge
• Vaccinations
• Car seat use

Mental health:

• Postpartum blues OK days 3-10
• If symptoms persist > 2 weeks or worsen → postpartum depression — call provider
• Warning signs: anhedonia, hopelessness, thoughts of harming self/baby
• Support resources

Warning signs to report:

• Excessive bleeding (saturating pad < 1 hour)
• Foul-smelling lochia
• Fever > 38°C
• Severe pain
• Signs of mastitis
• Wound issues
• Calf pain (DVT)
• Severe headache, visual changes (late-onset preeclampsia)
• Mental health concerns

Follow-up:

• Postpartum visit at 6 weeks (or earlier per protocol)
• Pediatric appointment
• Lactation support
• Mental health resources

Newborn CPR (Infant CPR < 1 year):

• Recognize emergency: unresponsive, not breathing
• Call 911 (or have someone call)
• Begin chest compressions if no pulse or HR < 60 bpm
• Compression rate: 100-120 per minute
• Compression depth: 1.5 inches (about 1/3 chest depth)
• Compression location: Just below nipple line
• Compression technique: Two fingers (single rescuer) or two thumbs encircling chest (two rescuers)
• Ratio: 30 compressions : 2 breaths (single rescuer); 15:2 (two rescuers, healthcare)
• Allow chest to fully recoil
• Continue until help arrives or baby responds

Choking infant:

• Mild obstruction (coughing, gagging) — allow to clear
• Severe (silent, blue, can't breathe) → action needed
• 5 back blows between shoulder blades
• 5 chest thrusts (just below nipple line)
• Alternate until object expelled or unresponsive
• If unresponsive: start CPR

Safe Sleep (AAP recommendations):

• Back to sleep — always supine
• Firm mattress, fitted sheet — no soft surfaces, sofas, pillows
• No bedding or soft items in crib — no blankets, bumpers, toys, pillows
• Room-sharing without bed-sharing — crib/bassinet in parents' room for first 6-12 months
• Smoke-free environment
• Avoid overheating — sleep clothing not too heavy
• Pacifier at sleep (after breastfeeding established)
• Tummy time when awake and supervised
• Breastfeed if possible — reduces SIDS
• Routine immunizations
• No commercial devices claiming to reduce SIDS (positioners, wedges)

Why infant CPR differs from adult:

• Smaller compression depth
• Faster compression rate
• Different technique (fingers vs hands)
• Most pediatric arrests are respiratory in origin
• Quick rescue breaths and oxygenation often resolves

SIDS (Sudden Infant Death Syndrome):

• Unexplained death in infants < 1 year
• Peak: 2-4 months
• Risks: prone sleep, soft bedding, smoking, overheating, prematurity
• Protective: back sleep, breastfeeding, pacifier use, room sharing
• Significant decline in SIDS rates with "Back to Sleep" campaign

Sleep environment safety:

• Crib or bassinet meeting current safety standards
• Firm mattress (don't test by softness — should be firm enough that head doesn't indent)
• No gap > 2 fingers between mattress and crib
• Crib slats no more than 2-3/8 inches apart
• Avoid hand-me-down cribs (may not meet current standards)

Bed-sharing risks:

• Increased risk of SIDS, suffocation, falls
• Especially dangerous: sofa, recliner, soft surfaces, adult bed with bedding, parent who smoked, drank alcohol, used drugs
• Bed-sharing not recommended
• Room-sharing IS recommended

Pre-discharge teaching:

• Demonstrate infant CPR (mannequin if possible)
• Have parent return demonstrate
• Provide written/visual materials
• Refer to community CPR class (AHA Family & Friends or HealthCare Provider)
• Encourage all caregivers to learn

CPR teaching points:

• Recognize: unresponsive, not breathing, blue
• Call 911 first if alone (or send someone)
• Begin CPR (no pulse or HR < 60)
• Position infant on back on firm surface
• Compressions: 2 fingers, just below nipple line, 1.5 inches deep
• Rate 100-120/min
• Ratio 30:2 (single rescuer)
• Open airway: head-tilt chin-lift (don't hyperextend in infant)
• 2 breaths: cover mouth and nose with rescuer mouth, gentle puffs
• Continue until EMS arrives

Choking infant teaching:

• Recognize severe choking (silent, blue, can't breathe)
• Position face-down on forearm, head lower than body
• 5 back blows between shoulder blades
• Turn over, face up
• 5 chest thrusts (just below nipple line)
• Alternate until object expelled or unresponsive
• If unresponsive: start CPR; check mouth for visible object before each set of breaths

Safe sleep teaching:

• ABC: Alone, on Back, in Crib
• Demonstrate proper sleep position
• Demonstrate proper crib setup
• Address questions and barriers
• Show videos if available
• Provide handouts

Common questions:

• "What if baby spits up on back?" — natural mechanism protects airway; less choking risk on back actually
• "What about head flat spots?" — supervised tummy time prevents
• "What about cold?" — wearable blanket/sleep sack instead of loose blankets
• "Bed-sharing is cultural" — discuss risks, alternatives like cosleeper

Address environment:

• Crib safety (current standards)
• Mattress firmness
• Smoke-free environment
• Bedroom temperature
• Pacifier at sleep (once BF established)

Resources:

• Local CPR classes
• Safe Kids USA
• AAP safe sleep resources
• Hospital lactation/safety education

Fertility awareness-based methods (FABM): tracking signs of ovulation and avoiding intercourse during fertile window OR using protection. Methods range from less effective to more effective with correct use.

Common methods:

• Calendar/rhythm method: tracking cycle length over months; identify fertile window (typical: day 8 to day 19 of cycle assuming 28-day)
• Basal Body Temperature (BBT): daily temperature on waking; rise of 0.5-1°F indicates ovulation has occurred
• Cervical mucus (Billings): egg-white, stretchy, slippery = fertile
• Symptothermal: combines BBT, cervical mucus, calendar — more accurate
• Cervical position: high, soft, open during ovulation
• Ovulation predictor kits (OPK): detect LH surge in urine
• Lactational amenorrhea method (LAM): exclusive breastfeeding < 6 months postpartum with amenorrhea — 98% effective if all conditions met

Effectiveness:

• Perfect use: 1-5% failure rate
• Typical use: 12-24% failure rate
• Symptothermal method most effective among NFP

Female menstrual cycle:

• Follicular phase: variable length
• Ovulation: ~14 days before next period
• Luteal phase: 10-16 days (more consistent)
• Sperm can survive up to 5 days; egg viable 24 hours
• Fertile window: ~6 days (5 days before to 1 day after ovulation)

Signs of fertility:

• Cervical mucus changes: dry → sticky → creamy → stretchy/clear (most fertile) → dry
• Cervical position: low/firm/closed (non-fertile) → high/soft/open (fertile)
• BBT: drop just before ovulation, then rise 0.5-1°F after ovulation
• Mittelschmerz (ovulation pain — some women)
• Breast tenderness, libido changes
• LH surge: detectable in urine 24-36 hours before ovulation

Why NFP appeals:

• No medications or devices
• Compatible with religious beliefs
• No side effects
• Increased body awareness
• Inexpensive (long-term)
• Can be used to achieve pregnancy
• Reversible immediately

Limitations:

• Requires daily tracking
• Irregular cycles make less reliable
• Doesn't protect against STIs
• Requires partner cooperation
• Less effective with poor adherence
• Stress, illness, travel affect cycle
• Postpartum, perimenopausal women less reliable
• Requires training/coaching

Pre-counseling:

• Assess motivation, commitment
• Partner involvement
• Regular cycle history
• Discuss effectiveness rates
• Discuss STI prevention (this doesn't protect)
• Compare to other methods
• Refer to FABM educator/instructor

Calendar/rhythm method teaching:

• Track 6+ cycles to determine cycle length
• Shortest cycle - 18 = first fertile day
• Longest cycle - 11 = last fertile day
• Avoid sex during fertile window

BBT teaching:

• Special BBT thermometer (sensitive to 0.1°F)
• Take same time each morning before getting up
• Chart daily for 3-4 months
• Identify thermal shift (rise of 0.5-1°F sustained 3 days)
• Ovulation occurred 1-2 days before rise
• Avoid sex from period to 3 days after thermal shift

Cervical mucus teaching:

• Check daily (before urinating)
• Wipe with toilet paper, observe
• Document: dry, sticky, creamy, stretchy/clear
• Most fertile = clear, stretchy (egg-white)
• Avoid sex during stretchy mucus through 3 days after peak

Symptothermal:

• Combine BBT + cervical mucus + calendar
• More accurate than single method

LAM (lactational amenorrhea method):

• Must meet ALL: exclusive breastfeeding, no formula/water, less than 6 months postpartum, amenorrheic
• 98% effective if all met
• Plan transition to another method by 6 months

Considerations:

• Cervical mucus affected by infections, medications
• BBT affected by illness, sleep, alcohol
• Stress affects cycle
• Multiple methods more reliable

If pregnancy occurs:

• Earlier than expected EDD calculation
• Use ultrasound for dating

Combine with backup method:

• Condom during fertile days
• Increases overall effectiveness
• Adds STI protection

Resources:

• NFP educators (Couple to Couple League, Creighton Model, etc.)
• Apps for tracking
• Books, online resources
• Healthcare provider consultation

Barrier methods prevent sperm from reaching the egg. Some also reduce STI transmission. Include male/female condoms, diaphragms, cervical caps, sponge, spermicide.

Male condoms:

• Most common barrier
• Latex (most common; some allergies), polyurethane, polyisoprene, lambskin (doesn't prevent STIs)
• Single use, fitted over penis before contact
• Effectiveness: ~85% typical use, ~98% perfect use
• Protects against STIs
• Available OTC

Female (internal) condoms:

• Nitrile pouch with rings
• Inserted into vagina before sex (can place hours before)
• Effectiveness: ~79% typical use, ~95% perfect use
• Protects against STIs
• Available OTC

Diaphragm:

• Silicone or latex dome with flexible rim
• Inserted with spermicide before sex; left in 6 hours after
• Effectiveness: ~88% typical use, ~94% perfect use
• Reusable
• Requires prescription, fitting
• Refit after weight changes, pregnancy
• NO STI protection

Cervical cap (FemCap):

• Smaller than diaphragm, fits over cervix
• Used with spermicide
• Effectiveness: ~71% typical use parous; ~86% nulliparous
• Less effective in women who have given birth
• Prescription needed
• NO STI protection

Contraceptive sponge:

• OTC
• Contains spermicide
• Effectiveness: ~76% parous; ~88% nulliparous
• Less effective in women who have given birth
• NO STI protection

Spermicide alone:

• OTC
• Foam, gel, film, suppository, cream
• Effectiveness: ~72% typical use
• Less effective alone
• NO STI protection
• Can irritate (especially nonoxynol-9)

Mechanism:

• Physical: prevent sperm from entering uterus/tubes
• Chemical (spermicide): kills sperm
• STI protection (condoms): physical barrier to microorganisms

Why use barrier methods:

• Hormone-free
• Available OTC (most)
• Use only when needed (no daily compliance)
• Effective immediately
• Compatible with breastfeeding
• STI protection (condoms only)

Limitations:

• Must be used correctly every time
• Can interrupt spontaneity
• Latex allergies possible
• Spermicide may cause irritation, increase HIV transmission (with nonoxynol-9 frequent use)
• Some methods less effective in parous women
• Most don't protect against STIs

Allergies:

• Latex allergy: use polyurethane or polyisoprene condoms
• Spermicide sensitivity: try different brands or methods

Storage:

• Condoms: cool, dry place (not wallets, glove boxes — heat damages)
• Check expiration dates
• Don't use damaged packaging

Patient counseling:

• Discuss all options
• Patient values and lifestyle
• STI risk
• Effectiveness
• Comfort with method
• Partner involvement

Condom teaching (key points):

• Use new condom for each act
• Check expiration date
• Open package carefully (no fingernails, scissors)
• Pinch tip to leave space for ejaculate
• Roll down to base of erect penis BEFORE any contact
• Hold base when withdrawing
• Use water- or silicone-based lube (not oil-based with latex)
• Dispose properly
• If breaks or slips: emergency contraception, STI screening

Diaphragm teaching:

• Wash hands
• Apply spermicide inside dome
• Insert into vagina, fit over cervix
• Check placement (cervix covered)
• Leave in 6 hours after sex
• Don't leave > 24 hours (TSS risk)
• Reapply spermicide if more than one act of sex
• Clean after use
• Refit after: weight change > 10 lbs, pregnancy, surgery

Cervical cap teaching:

• Similar to diaphragm
• Smaller learning curve
• Can leave in 48 hours
• Spermicide

Sponge:

• Wet with water before insertion (activates spermicide)
• Insert against cervix
• Leave 6 hours after sex (up to 30 hours total)

Spermicide:

• Use 10-15 minutes before sex (allow to disperse)
• Reapply for each act
• Most effective combined with another barrier

Combine with other methods:

• Condoms + diaphragm/spermicide for additional protection
• Backup for fertility awareness
• Always backup if missed pill

STI prevention emphasis:

• Condoms only barrier that protects against STIs
• Use condoms with new partners
• Use condoms even with hormonal contraception for STI protection

Emergency contraception:

• If condom breaks: emergency contraception within 5 days
• OTC: levonorgestrel
• Rx: ulipristal acetate, copper IUD