Revision for Postnatal Placement Flashcards
What babies on the postnatal ward may need increased care on the PN ward due to increased risk of medical morbidities, feeding difficulties and re-admission?
- Late preterm babies (>36+0/40)
- Weight 10%
- hypoglycaemia
- jaundice
- congenital abnormalities (e.g. down syndrome, cleft lip/palate)
- other risk factors related to feeding
What assessments are vital in assessing the wellbeing of babies who require extra care on the PN ward?
- vital signs (temperature, heart rate, respiratory rate)
- tactile warmth
- colour
- output
- hydration
hourly for 4 hours then before feeds/ 4 hourly for 24 hours - signs of jaundice
- weight at 24 hours
- ? blood sugar levels
What is the best way of preventing hypothermia?
immediate and uninterrupted skin-to-skin contact
- consider review if 2 hours despite skin-to-skin
What are some signs that supplemental feeds (preferably EBM) may be required for babies requiring extra care? These signs may indicate that discharge should be delayed
- less than 10 minutes effective breastfeeding at most feeds
- weak, disorganised, immature suck patterns
- less than 4-5 wet nappies per day after 96 hours
- > 10% weight loss post birth
- weight
What midwifery care should be provided prior to discharge from PN ward for babies requiring extra care?
- referral for home visits as required for followup
- assessed by neonatal doctor
- written discharge feeding plan
- assessment of output (wet/dirty nappies), weight loss/gain
- parent education
In educating parents prior to discharge, what signs should be highlighted as reasons to access further care for their baby?
- lethargy
- poor feeding
- vomiting (particularly large after several feeds, or if green)
- pale
- excessive crying
- jaundice
- less than 5-6 wet nappies in 24 hours
- fever, rash
- difficulty breathing
- turning blue
If parents are concerned about their babies wellbeing what might they do depending on the issue and their level of concern?
- discuss with home visiting midwife
- visit emergency department
- see GP
- call ambulance
What are some other contacts in the community that may be able to help if parents are concerned?
- Australian Breastfeeding Association 24 hour helpline
- MCHN helpline
What assessments should be undertaken by midwives during postnatal home visits for babies requiring extra care?
- routine care
- assessment of early breastfeeding
- vital signs
- signs of jaundice
- tactile warmth, colour, alertness and frequency of feeds
- output
- hydration
- assessment of behaviour, sleeping and crying
- weight
- assessment supplementation
What are some risk factors for adverse outcomes associated with feeding difficulties?
Maternal
- history of insufficient milk supply or underweight baby
- lack of previous breastfeeding
- age > 37
- nipple trauma, flat or inverted nipples
- previous breast surgery or breast abnormalities
- excessive, prolonged breast engorgement
- perinatal complications - labour medications, assisted birth, prolonged labour, induction, PPH, hypertension, infection
- preexisting conditions - obesity, diabetes, endocrine disorders
Baby
- preterm
- birth weight 7-10%
- poor output
- multiples
What is expected for babies in terms of weight changes post birth?
- very normal for babies to loose weight in the first few days post birth
- weight loss>10% requires further assessment
- about 20-30g weight gain/day (or about 150-200g/week) expected after day 4-5
- usually regain birth weight by day 10-14
What is expected in terms of babies outputs after birth?
- At least 5 clear wet nappies per day
- at least 1 soft yellow poo per day
- no urates after day 3
- other signs of good hydration
After the first 24 hours, how many times is normal for babies to need to breastfeed?
8-12 effective feeds in 24 hours
What is expected in terms of frequency of formula feeds per day?
6-8 feeds per day
If If there are concerns about a baby’s weight, feeding or outputs what should be assessed and what care should be provided?
if concerns about hydration or milk supply refer to emergency - particularly signs of unwell, poor perfusion or breathing difficulties
otherwise assess breastfeeding positioning, attachment, frequency, supplementation, formula feeding/preparation, follow up visit, consider referral to LC
How can midwives in the birth room support breastfeeding for the well term baby?
- immediate uninterrupted skin-to-skin contact for at least 1 hour or until after first feed
- assess vital signs, breathing, colour and tone without interrupting skin-to-skin
- educated about feeding cues
- help position mother/baby for first feed
What are some early feeding cues?
- crawling movements
- mouthing
- vocalising
- hand-to-mouth
- searching for the nipple
- rooting
- rapid eye movements
- waking from sleep and becoming restless
- sucking hands
What are some recommendations you might give a women about breastfeeding?
- should be flexible, unrestricted and on-demand
- offer both breasts, alternating the starting breast
- allow baby to finish at first breast before offering second
- length of feeds is very variable
- skin-to-skin can facilitate establishment of breastfeeding
When assessing breastfeeding what should you be looking for?
- breasts (soft, firm, colour, pain)
- nipples (cracks, blisters, trauma, shape, flat/inverted)
- positioning
- attachment
- signs of milk transfer
- frequency
- output
- hydration
- jaundice
- weight loss
When educating parents, what are signs of adequate milk intake?
- baby mostly settled between feeds, although common to have periods where unsettled and very frequent feeding
- rhythmic sucking and swallowing may be seen or heard
- breasts feel fuller at start of feed and softer at end of feed once milk is in
What are are the recommendations around giving breastfed babies supplementary feeds in the early postnatal period?
- supplementation with formula not required in first 24 hours in the healthy term newborn
- supplementation should only be recommended if there is a medical reason
- EBM is first choice if supplementation required
- formula should only be given if there is a medical indication and there is insufficient EBM
- feeds should be given by cup, syringe or spoon
- bottles, teats and pacifiers should be avoided
If a baby has had uninterrupted skin to skin and a first breastfeed, what is normal in terms of when the next feed is likely to be?
- baby should be allowed to sleep for up to 8 hours until it shows readiness to feed
- ongoing skin to skin contact should be encouraged
What are the minimum set of observations for newborns?
- heart rate
- respiratory rate
- temperature
- skin colour
- oxygen saturation (postductal between 6-24 hours)
- As appropriate: cord, check ID labels, weigh, assess feeds, stools, urine, hearing screen, length, head circ, transcutaneous billirubin, newborn screening test
Why is postductal oxygen saturation measured routinely in newborns?
as screening for congenital heart and non-cardiac conditions that may otherwise be missed
What are some signs of adequate breastfeeding?
- frequency (6-12 times in first 24, 8-12 times>24)
- swallowing
- content after most feeds, looks healthy, good skin tone and bright eyes
- 1 wet nappy per day of life
- stools - mec to 48h, trans72)
When should baby observations be done on the newborn?
- after birth
- hourly for first four hours
- if under neonatal medical care or if there are other indications
In the ISBAR mnemonic for handover what does I stand for?
Introduction
- identify self, role and location
In the ISBAR mnemonic for handover what does S stand for?
Situation
- What is happening?
In the ISBAR mnemonic for handover what does B stand for?
Background
- what is the clinical background?
In the ISBAR mnemonic for handover what does A stand for?
Assessment
- what are the observations? what do you think the problem is?
In the ISBAR mnemonic for handover what does R stand for?
Recommend
- what do you recommend? want the person you called to do? be clear and specify timeframe
In terms of breastfeeding codes, what does A usually refer to?
Mother unassisted
In terms of breastfeeding codes, what does B usually refer to?
Midwife assistance given
In terms of breastfeeding codes and attachment, when is it common to score a 6 and what does it refer to?
- regular suck and swallow >10 minutes
- usually first feed after birth and >72 hours
In terms of breastfeeding codes and attachment, when is it common to score a 3 and what does it refer to?
- attached, irregular suck and swallow
- usually first 48 hours
- if >48 hours score 4 and suspect poor attachment
In terms of breastfeeding codes and attachment, when is it common to score a 5 and what does it refer to?
- attached, regular suck and swallow 10 minutes, generally >72 hours
What is the usual indication for administering vitamin K?
- prophylaxis of hemorrhagic disease of the newborn
What is hemorrhagic disease of the newborn?
- a newborn bleeding disorder
- may impact 2-5 babies out of every thousand untreated babies
- breastfed at greater risk than formula fed
What equipment do you need to give a newborn vitamin k injection?
- kidney dish
- 1ml syringe
- drawing up needle
- 23 gauge 25mm needle for term baby OR 25 gauge 16mm needle for small or prem baby
- 7% alcohol swab
- cotton wool ball
- vitamin K ampoule (stock strength usually 2mg in 0.2ml)
What is the usual dose of vitamin K?
1mg in 0.1ml
- if baby
What is the usual procedure for administering vitamin k?
- obtain consent
- two midwives to check drug order, the vitamin k and the baby labels
- hand hygiene
- inject IM (90 degrees, no need to draw back) usually before transfer to PN ward, usually into lateral aspect of babies thigh, into opposite thigh used for injection of hep b or other medications (may also be given orally)
- apply gentle pressure with cotton ball
- discard sharps
- settle baby
- hand hygiene
- sign medicine chart and document
What is the procedure for giving vitamin k orally?
- 3 doses of 2mg (0.2ml)
- at birth
- at 3-5 days (usually with newborn screening)
- at 4 weeks
What are the generic and trade names for vitamin K?
- phytomenadione
- Konakion
What is the normal temperature for a newborn baby (per axilla)?
36.5-37.1C
What is the normal heart rate for a newborn baby?
- 100-160bpm
- healthy term and pink
What is the normal respiration rate for a newborn baby?
30-60 breaths per min
- no signs of respiratory distress
