Module 1: James Flashcards
A newborn infant is always?
Vulnerable
Early discharge increases?
Vulnerability
Liz is a community health nurse whose clients include a large number of childbearing families. Today she has four visits scheduled — all postpartum mothers and their families.
The first visit this morning will be to Marnie and her newborn son James. A brief review of the birth summary record reveals the following information about Marnie and James:
Mother four days postpartum Marnie 39 years old G3 T1 P0 A1 L2 Sibling Jackie female 2½ years old Pregnancy history spontaneous abortion 13 months ago Jackie born 2 ½ years ago via C-section Birth history attempt at vaginal birth unsuccessful cesarean section for failure to progress (VBAC) epidural anesthesia blood loss 560 cc delivered live male, James — birth weight 3661 grams Social single parent — separated from James’ biological father accountant with large firm mother and sister supportive
Identify any “red flags” or areas of concern you note from Marnie’s history and present situation. In order to do this, you will likely have to refer to your textbook for more information regarding maternal age, failed VBAC, cesarean section, blood loss, etc.
There are several things in Marnie’s history that I would take note of and keep in mind as I assess her needs for follow-up. Here are a few. You may come up with different and/or more concerns.
maternal age > 35 years — many women are having their children later in life. Some controversy exists regarding the risk for women having children later in life. Many argue that women today, including those over 35 years, are healthier than they were in their twenties. On the other hand, the reproductive organs have aged as a woman approaches 40. As is so often the case, each woman is uniquely individual.
previous pregnancy loss — increased risk for postpartum depression or at least postpartum adjustment
single parent — as above
epidural for cesarean section — associated with increased jaundice and decreased breastfeeding
pain— impedes effective breastfeeding
blood loss > 500 ccs — associated with decreased prolactin levels
What are your thoughts regarding the language or terms used in the history notes?
There are many places in the language of maternity care that the word “failure” is used: “failed VBAC”; “failure to progress”; “failure to thrive.” There are other terms used in relation to breastfeeding that denote failure using different words, such as “insufficient milk supply.” What kinds of messages are we sending new parents when we use these words and phrases?
Sometimes nurses resort to using these terms rather than searching for new ones because we all know their meaning. However, it is helpful for us to reflect on the messages we are giving to parents and to be conscious of the reactions we may elicit.
Liz arrives at 0945. Marnie opens the door and the women introduce themselves.
A little girl is lying on the couch watching Sesame Street on TV with a blanket tucked under her chin.
Marnie offers Liz a cup of tea. As Marnie is pouring the tea Liz asks: “So how are things going?”
“Not too bad really … Jackie, my toddler there, has been an angel. My mom and my sister have already been in to see me, and James seems to be doing fine.”
“Great. How are you feeling?”
“Oh, I’m OK … really tired and I’m still having some pain in my incision. Feeding time is pretty tough.”
Liz began with an open-ended question that allows Marnie to set the agenda and identify what her priorities are. This is an important aspect of family-centered care because you may find that sometimes the issues that are paramount for a client are not always what you might think they would be or even should be.
The important thing is that we give parents a chance to identify their own needs.
Consider starting with how a mother is feeling. Often much attention is given to a new baby by friends and relatives that mothers may feel secondary. You’ll notice that Marnie’s first response addressed how everyone else was doing. Unless you directly ask mothers about themselves, you may miss important information: for example, pain or how they are coping.
“So tell me a little more about what you mean when you say feeding time is pretty tough.”
Marnie tells Liz that the end of her incision line hurts especially when she gets up and down from bed. In order to feed James she has to “slouch” in bed to relieve some of the pressure on her stomach. She is taking the Tylenol with codeine that she was prescribed in the hospital.
On examination, Liz finds Marnie’s incision to be slightly reddened at the left end of the incision line; however, it is clean, dry, and well approximated. It is tender to palpate, but not warm. Marnie is afebrile.
Liz reassures Marnie that the incision does not appear to be infected.
Given what you know about the interactive and interdependent nature of the mother-infant relationship, what, if any, impact do you think maternal pain might have on “development of trust” and “attachment”?
The need to stay on top of pain is required in order to care for oneself, let alone a newborn and toddler. Many mothers will express feelings of irritability, anger, bitterness, and a sense of “distance” or “dopiness.” Often, they do not relate this to the pain and the possible connection is a surprise to them. Needless to say with these or other similar feelings present, mothers may have a difficult time developing an attachment to their infants and may find basic care and nurturing, such as breastfeeding, difficult.
What kind of complications are associated with early discharge?
Breastfeeding issues, jaundice, postpartum depression and sibling adjustment. One of the complications of early discharge is that those mothers and families who experience problems at home are vulnerable because the problems may go unrecognized and therefore untreated.
To allow mother’s to make an informed decision to breastfeed what is important?
t is important to educate childbearing women and their families about the benefits of breastfeeding, anatomy of the breast, physiology of breastfeeding, sources of support and information, and alternative methods of feeding expressed breast milk.
What are contraindications to breastfeeding?
- women with active breast malignancies who are undergoing chemotherapy or radiation therapy
- women who are human immunodeficiency virus (HIV) positive or who have the acquired immunodeficiency syndrome (AIDS)
- women who engage in recreational drug use
- women who are on certain prescription drugs. Current research tentatively suggests that, for most psychotropic medication, low doses of a single drug are relatively safe during breastfeeding (Kohen, 2005). However, the author states that all “mental health professionals involved in the management of women’s psychiatric problems during the perinatal period have to make an individualized risk/benefit analysis to advise each woman on medication while pregnant and the possibility of safe breastfeeding” (p. 376).
Milk of other species that is fed to human infants has been known to contribute to increased _________ ____.
infant mortality risk
What are the advantages of breastfeeding a preterm infant?
- Protection from Nec
- Protection from infection or sepsis
- Increased feeding tolerance
- Earlier attainment of full enteral feedings, which is associated with a significant reduction in late onset sepsis among extremely premature infants.
- Decreased risk of later allergy
- Improved retinal function
- Improved neurocognitive development and brain growth
- Suppression of oxidative stress
What is breast milk composed of?
breast milk satisfies the nutritional needs of the infant being rich in carbohydrates, fat, protein, vitamins, and minerals
Breastmilk has three characteristic phases. What are they?
colostral, transitional, and mature
Colostrum
During the first three days, the breasts produce colostrum, a clear yellowish fluid which is low in volume but high in density and rich in protein and immunoglobulins.
Transitional milk
During days 3−10, a phase referred to as transitional, colostrum gradually changes to mature milk; this is referred to as “the milk coming in”
Mature Milk
Mature milk is high in volume and consists of more lactose and fat but less protein than colostrum. “By days 3−5 after birth, most women have experienced this onset of copious milk secretion”
Foremilk
foremilk is lower in fat and energy content then hind milk.
Human Milk vs. Cow Milk
- only 10% of iron is absorbed from formula, whereas 80% is absorbed from human milk.
- Cow’s milk forms indigestible curds much more easily and thus delays gastric emptying.
- 95% of human milk protein is nutritionally available to term infants, whereas the GI immaturity of the preterm infant enables four to six times higher daily losses of human milk protein if human milk is pasteurized or has cow’s milk-based fortifier added.
Preterm vs. term breastmilk
1) preterm breastmilk has increased protein content
2) whey, has a more physiologic balance of amino acids and contain many anti-infective properties.
3) the lipid content in preterm breastmilk is more specific for the preterm infant
4) lactose, the major carb in breastmilk has increased absorption in preterm infants
5) IGA concentrations are higher
In NICU there are 4 critical exposure periods for premature infants to human milk have been identified what are they?
1) colostrum in the transition from intrauterine to extrauterine life
2) transition from colostrum to mature milk in the first month of life
3) the amount of human milk feeding throughout the NICU stay
4) human milk feeding after discharge
What is lactogenesis?
Lactogenesis is the initiation of milk production
What is Galactopoiesis?
Galactopoiesis is the process of ongoing milk production and is influenced by several contributing factors including sensory stimulation, breast emptying, supply and demand, and the milkejection (let-down) reflex.
What is important for milk transfer?
compression + suction
What are two critical principles of breastfeeding?
- positioning and latching technique
- knowledge of frequency and duration of feeds
Liz asks Marnie, “You said that breastfeeding is difficult because of the pain so let’s talk about the feeding a little more.”
After some discussion and clarification, Liz finds out that:
Marnie is feeding James q 4–5 hours
James feeds for approximately 5–10 minutes each side
Marnie is supplementing with 1 ounce of formula after each feed
Marnie’s nipples are sore
James is sleepy at the breast
James has 6–7 wet diapers and 1 BM in 24 hours
Liz asks Marnie why she is supplementing.
Marnie tells Liz of her breastfeeding experience with her daughter: “Oh, I am just so anxious that I don’t have enough milk. You see I had some trouble with Jackie … actually I was a mess. My milk came in late and we just couldn’t seem to get started. Jackie ended up with poor weight gain and failure to thrive. My mom brought me some formula when she visited last night … just in case. She’s really worried that the same thing is going to happen this time. I guess I’m worried too.”
Liz decides to spend some time discussing breastfeeding with Marnie. She begins with an explanation of supply and demand. Later, she plans to address Marnie’s concerns regarding failure to thrive.
{case-callout-end}
Marnie asks you how she will know when the baby wants to feed. What would you tell Marnie?
I would tell Marnie that when her baby is hungry he may:
- bring his hands to his mouth.
- root (turning towards her breast and open his mouth).
- make mouthing and sucking motions.
What would you do to help Marnie prepare for the James’ feed?
I would help Marnie get into a comfortable position (either sitting or lying down), using pillows to support her back, head, and both her arms. I would then help her to position her baby to facilitate feeding.
The baby should:
- be belly-to-belly, and preferably skin-to-skin, with Marnie.
- be propped on pillows or supported so that his body is level with Marnie’s breast.
- have his head and body in a straight line (the baby should not have to turn his head to reach the breast).
