OB exam 4

• make the child feel safe, secure and protected 
• NOT play with and entertain child

essential

cant

• cry less
• learn to self-soothe
• respond more appropriately to caregiver

• infants behavior call- corresponds with behaviors from parents
• Crying- parents attend to infant
• Delayed: temperament, social capabilities, appearance, gender

Baby gives clear behavioral cues -- caretakers response predictable -- mother will feel effective & confident

• Infant behavioral cues (smiles, breasfeeds eagerly, grasps finger, consoles easy, like cuddlin)
• Claiming process--likeness--differences--unique

• Feeding = excellent time to observe
• Fantasy about “ideal” baby – birth, fantasy becomes real
• Do they reach for infant? Call infant by name? ID special things?
• Body contact? Talk to baby? Make eye contact? Comfortable w/ providing care?
• Express concerns/disgust? Show affection? Use comforting techniques?

no sustained eye contact, evil eye

• babies move in time with structure of adult speech
• culture determines rhythms- ingrained long before first words

• baby's heart beats in tune with moms
• lay baby on chest
• record heart beat

• body movement/behavior that provides the observer with cues
• caregiver interpretes and responds

• taking in
• 1st 24-48hrs – mom’s needs predominant
• She needs mothering
• Relies on others to fulfill needs for comfort, rest, food, closeness to family
• Mom talks about birth story – excited, talkative

• Taking hold
• 2-10days after Focus on baby & competent mothering
• Desire to take charge
• Eager to learn/practice
• Handles discomfort & emotional changes
• Possible “baby blues” – r/t hormones
• Desire for nurturing & acceptance from others
• Uncertain, trapped, overwhelmed –1st time moms

• Letting go
• Focus on family unit
• Reassert partner relationship and physcial intimacy
• Resolve individual roles
• Homemaking, career, marital relationship

• Stage 1: expectations
• Stage 2: REality-Sadness (ambivalence. Jealous. Frustration. Overwhelming desire to be involved.)
• Stage 3: Transition to Mastery (conscious decision to take control and be more active)
• 1st few weeks: uncertain. Increased responsibility. Disruption of sleep. Can't control time needed for infant care. Re-established marital dyad

play

• Knowledge deficit, inexperience, immaturity, difficulty recognizing problems/resources, unmeet developmental needs of teens
• Feel different from peers
• Excluded from “fun” activities
• Prematurely forced into adult role
• Conflict b/w own desires & baby’s demands
• Relationship w/ father beneficial
• Less verbal, less attentive Less knowledge of child G&D
• Assume maternal role that they experienced
• Encourage family to be involved

• Crisis mode – teen tasks, transitioning in parenthood, & adapting to marriage/cohabitation
• Encourage dad to go w/ mom to PP & well-baby check ups
• Support – finances, child care, parenting skills, reproduction, birth control, safe sex

• showing interest
• maintaining their interpendence

• regression
• aggression
• attention seeking beahviors
• whining
• usually passes quickly

• Parents attitude sets the stage
• Jealousy after interest worn off
• Actively involve them in prep for new baby
• Take 1st born to hospital – compare to his/her birth
• Have small gift from baby to sibling – or sibling to baby
• Arrange sib to be the 1st one to hold baby
• Plan time for each child
• If preschoolers/early school age – give them a “baby” to care for
• “I’m a big brother t-shirt”
• Give photo of baby for sib to take to school
• Supervise interaction b/w siblings
• Initial behaviors – looking & touching
• Let kids interact @ own pace

• Respond to adult kids depending on their view of childbirth, childrearing, & roles
• Life-transition
• Maternal grandparents – higher expectations for themselves – may be self-critical
• Sometimes adult kids may not want help
• Involvement depends on: willingness to help, proximity, & ethnicity/culture
• GP: respect autonomy, parents wishes & remain available 4 million
• GP had primary responsibility for grandkids (2010)

• positive attitudes and realistic expectations
• nurturing behaviors
• verbalizing plus factors in lifestyle change

• lack of knowledge of infant care
• feelings of incompetence
• unrealistic expectations
• fatigue from interrupted sleep

• role transition
• unwanted pregnancy
• lack of support

• difficult birth
• postpartum complications
• neonatal complications

• Home visits ideal
• Anticipatory guidance on transition to home
• Written info
• List available resources
• Classes
• Disposable diapers Preparing frozen meals before birth
• Time discharge to provide adequate time to “settle in” before feedings
• Provide ready-to-feed bottles for 24-48hrs
• Assert need to limit visitors
• Signal partner w/ mom needs rest
• Let family know how they can help
• Keep mom in robe
• Mom should limit activity
• Rest when baby rests – environment conducive to rest & family plan
• Adequate nutrition

• meconium, extracellular fluid, low fluid intake
• >10% loss is concerning but no dehydration
• 7-10 days-regain birth weight
• gain 35g/day
• formula babies regain quicker

140-160 mg/kg/day

DO NOT NEED EXTRA WATER

Increased surface area to body ratio, hgih water content, low kidney function

100-115 kcal/kg/day

• 15% of calories
• Long chain polyunsaturated FA
• DHA & ARA
• Fat content ­ increased in PM, decreased in AM
• BM tailored to baby – preterm or term

• main energy source (40-50%)
• Lactose primarily (enhances absorption of Ca, Mg, zinc)
• Oligosaccharides promote growht of lactobacillus bifidus

• BM-predominanly Whey
• Need 2.25-4g/kg/day
• Easily digested and broken down
• Reason BF babies feed more ofetn

• Cows milk > casein
• Bigger curds when broken down

• BM low in Vit D (recommend: 400 if/day for babies getting <32 oz/day)
• Vit k=small quantities
• B12- only if mom vegan/vegetarian diet
• VIt A- rich in BM, helps prevent blindness
• Vit. E- essential, esp. preterm (In BM and formula)

• BM and formula adequate
• Dont recommend low-iron formula
• IRON DOES NOT CAUSE CONSTIPATION IN INFANTS
• Constipaton- caused by casein in formula- firm rubbery curds

• dont assume baby lactose intolerant
• babies are not allergic to BM, may be allergic to antigen in cows milk from mothers diet

15-20 lobes with lobules where milk secreted

milk flow

• hey hormone in breast feeding, sucking stimulates release
• if 3hrs lapse between sucking, prolactin rapidly decreases
• nurse every 1.5-2 hrs during day

Delayed: c section- first kid, long 1/2 stage, PP hemorrhage, stress, DM1, obesity, hx breas surgery

• water
• increase lactose and protein
• decrease fat

• rich in fat and calores
• more often breasts are empty, faster milk is produced

• intial milk, small volume
• thick, creamy, yellow
• concentrated: protein vitamins and minerals
• low fat and lactose
• lots of IgA
• Laxative effect- passage of meconium

• 32-96 hrs
• "coming in" milk
• yellowish, copious amounts
• more fat, lactose and calories
• by day 5, produces 16 ml/day

• by 2 weeks
• white or blue tinged
• looks thin but very nutritious
• by 6 months- 800 ml/day

• HIV pos
• Active TB
• Varicella
• Cnacer drugs
• Galactosemia
• Illicit drug use
• Smoking

• rich in lactose
• iron more easily absorbed
• decrease risk of: DM2, obseity, cancer, asthma
• Antibacterial, antiviral
• Still need vaccines
• Increased self esteem, enhanced bonding
• Mother: decreased PP hemorrhage, breast/ovarian cancer, DM2, RA, HTN

• Pain (nipple tenderness)
• Improper latch, position; engorgement, infection
• Leaking milk
• Embarrassment
• Stress
• Father is left out
• Diet restrictions – no alcohol or caffeine
• Limited birth control Progestin-only pills, depo shots ok if BF established
• Vaginal dryness – use water based lubricant; temporary

• no long acting meds
• Take after BF
• use alternatives if available
• Use single symtpom drugs
• Potential AE

• raglan
• Fenugreek- increase milk supply in 1-3 days
• Not recommended- ask DR before

• Initial in st 2 hrs after birth
• dont force
• helps oxytocin release
• helps mother learn cues
• promotes bonding
• facilitates meconium passage
• stimulates more milk

• hands to mouth
• sucking, rooting, mouthing
• regurgitation "wet burps"
• hiccups common
• after sleep, infant will want to feed

• BF every 1.5-3 hrs
• 8-12 feedings/day

• longer pauses between sucking
• total body relaxation
• release of nipple
• fall asleep

• honey
• cornsyrup

can cause botulism

6-8

nipple

• 8 hr in very clean conditions at room temp
• up to 8 days in fridge
• 6 months frozen
• Thaw in fridge for 24 hrs

BM

• 3-4 hrs
• 6-8 feedings/day
• larger volumes

• least expensive
• not sterile
• 1:2 ratio

• more expensive 
• 1:1 with sterile water

• most expensive
• sterile
• good if no clear water available

• Wash lid before opening
• Shake bottle after mixed
• Run tap water 1min before use, use cold water (b/c lead)
• Use only the scoop that comes w/formula
• Warm bottle by placing in warm water   ~15min
• Don’t let sit >2hrs
• Use 1 bottle/feeding
• Hold infant -- don’t prop bottle

• Distilled: acceptable, no Flouride
• Filtered Tap: acceptable
• Spring water: avoid!
• Tap water: safe
• Well water: not recommended, can be used if thoroughly tested
• Fluoride supplement >6mos.

• after 15 ml in first day of life
• then after 30

• rapid decrease in uterus size after birth
• healing of uterus

• prolonged labor
• anesthesia- muscle relaxation
• difficult birth and excessive manipulation
• grandmultipartiy
• full bladder- if they pee just a little= bladder overdistended
• retained placenta
• infection

1/2 way between symphasis and umbilicus

1 cm

• exfolation so no fibrous scar
• scar limits future implantation sites

round to slit

• spongy
• flabby
• bruised

2 fingers

1 wk- will admit fingertip

3 weeks

labia size

doesnt

• returns in nonBF mothers in 6 weeks (40%) and 24 weeks (90%)
• In BF mothers returns in 12 weeks (45%)

in 2-3 months with exercise

increased bright red lochia

• woman on side
• lift butt cheek

• Ice pack for 20min on 20min off
• Pericare w/ squirt bottle
• Sitz bath (105o)
• Topical anesthetic
• Avoid direct contact

• lochia rubra
• Dark red, w/ epithelia cells, RBCs, WBCs, deciduas, fetal waste
• NO large clots (quarter size)

• lochia serosa
• Brownish pink w/ serous exudates, deciduas, RBCs, WBCs, mucus, microorganisms

• lochia alba
• yellowish white with WBC, fat, mucus

musty

8-9 oz

AM, because pooling at night

• if <1:10= rubella vaccine
• must avoid pregnancy for 3 months

• rh- mom
• rh pos baby
• give within 72 hrs of delivery
• should have gotten a dose at 28 weeks and if trauma

1-2 days

• mom focus on herself
• body functions
• decreased interest in education

• concerns about being good parent
• receptive to teaching

• Persistent/spike in fever
• Change in lochia to earlier state or foul smell
• Mastitis
• Thrombophlebitis
• UTI
• Pelvic pain

• c sections and smokers
• increased risk pneumonia

• Pain r/t inflammation 2nd to breast milk suppression                                    Engorgement       To help – tight, supportive bra (24hrs/day); ice;decrease nipple stimulation; cabbage leaves                 
• For BF: decrease pain during latch on by 1st doing hand expression to provide cusion

• void every 2-4 hours
• If no void for 8 hrs- straight cath
• After cath removal, should pee within 1-3 hrs
• Have BM when she feels need to- DO NOT WAIT
• should have BM after 48 hrs

boggy and displaced uterus

• sitz bath
• anesthetic ointment
• lay on side
• adequate fluid
• colace

• check q15 x4 then q30 x2 then q4hrs and PRN
• Should be midline and firm
• If above umbilicus= clots
• If tipped to side= full bladder
• RF for boggy-multipara, full bladder, general anesthesia, not ambulating, lots of pain meds
• If boggy= empter bladder ambulate and massage
• Massage not routinely done b/c painful
• Massage if clots
• The more they pee- less risk of boggy and UTI
• Pain r/t afterpains
• Lie prone with pillowunder abd; sitz baths;ambuulation;  analgesic(motrin)

• Homan's sign
• if seen, measure both calfs

defensive

blood loss over 500 ml

• within 24 hrs of delivery
• Causes: uterine atony, laceration, retained placenta, blood coagulation
• RF: over distention of uterus, multiparity, anesthetic agents, trauma, prolonged labor, rapid deliver, use of Pitocin, uterine infection, malnutrition, anemia, PIH
• S/S: Slow/quick gush of blood from uterus or pool under uturus. Change in VS

• Prevent w/ adequate nutrition, good prenatal care, early dx of complications
• Avoid traumatic procedures, type & cross all pts.
• Fundal massage prn Methergine: for hemorrhage, causes smooth msucle contraction, oral
• If bleeding: bimanual massage, Pitocin rate increase, o2
• If bleeding continues: inspect genital tract by Dr, D&C, Prostin IM, blood transfusion, Coag profile, hysterectomy

• after 24 hrs
• Most common cause= retained placenta
• Presentation: few hrs after deliver up to 2-4 days
• Prvention: careful exam of placenta
• S/S: bogy uterus and bleeding
• Mgmt: IV pitocin, methergin, ATB, volume expanders, blood, D&C, estimate blood loss by weighing pads (1 ml=1g)

• Hx of malnutrition, anemia, debilitated condition
• RF: episiotomy, endometriosis

• 75% of mom’s have
• 3-7 days after delivery
• Mild depression, goes away itself – no tx needed

• 10-15% women
• Greater emotional distress, distorted thinking, debilitation
• Develops slowly over days – weeks
• s/s: crying, insomnia, appetite changes, feels worthless, little concern for appearance, irritable, loss of control

• 1-2% women
• Serious w/ potential for woman to kill herself &/or baby
• Delusional & hallucinations

• Normal INTENSE grieving – up/downs, for 18mos-2yrs.
• Crying acceptable & healthy expression of grief
• Bizarre delusions (phantom crying & aching arms) = normal
• Put off all major decisions for @ least 1yr.
• Give yourself sufficient time to mourn & recover (~1yr) before getting pregnant again
• For new pregnancy, choose new names –each child is unique
• Fathers should expect mother to have more intense feelings for longer time b/c bonding started before birth
• Let others know how you feel & how your working out your grief
• w/in 3mos, try to become involved in a support group
• The anniversary of birth & death can be stressful – be good to yourself & allow yourself some emotional space & time for grieving
• Have patients w/ yourself – make time for family, love your mate