New Grad Maternity Residency Question!

Postpartum RN · Nov 7, 2015

Congratulations!! This is such a difficult specialty to get into, so kudos!

Your orientation sounds very generous! 9 weeks should be plenty enough for post partum. I am getting 6 weeks, I'm almost done, and I feel great about starting on my own.

My friend got 8 shifts of orientation on postpartum at another hospital..yikes..but she says she is doing great right now.

Since I am new to this specialty as well I don't have that much advice. I keep a little notebook in my pocket where I write down some things that I can quickly reference to (even med room key codes and extension numbers for important phone numbers, so that as you are standing by the med room trying to figure out the code when no one is around-you can look it up real quick) I also wrote down common newborn tests and when they are done--there seems to be quite a few that are done and all have their specific time of age to be done.

They will teach you everything you need to know. Since my OB rotation was many years ago, I come home and read my maternity book and try to study.

Have fun and congratulations again!

missamelissy8 · Nov 7, 2015

Great! Thank you so much for your thoughts. My excitement just continues to grow, and I'll definitely keep your recommendations in mind!

NurseStorm, BSN, RN · Nov 10, 2015

I agree, very generous orientation :) Some words of wisdom.. :

1) breastfeeding- take a breastfeeding course or two on positioning and latch if you can before you start or during your preceptorship. Learn as much as you can from your preceptor about manual expression (very important when you can't get baby to latch), and ways of supplementing when baby can't latch (we do cup feeds- which I personally never usually do cuz I hate them, scared i'll spill, syringe feeds, finger feeds and SNS- supplemental nursing system which is a feeding tube attached to manually expressed or pumped colostrum tucked in while the baby is latched at the breast. In some cases if deemed necessary we can also use formula while doing this, with mothers consent of course). Breast milk pumped is like a med, label label label, and put date and time. ALWAYS clarify with the Mom before you give it, or if in a separate area with mom's permission be sure and double-triple check with bands.

2) Assessments- a) baby- I don't know how familiar you are, so if this is too basic you can just skim it. Newborn Head to Toe: Always initially observe colour, work of breathing (you can see nasal flaring, hear grunting, moaning, etc, even before you undress. Retractions can sometimes be noted while dressed even once you are used to them)- obviously if you notice distress you should address it and not continue the head to toe yet.., and

- tone. Floppy baby is not good! Increased tone also is not good. Research into tone and what causes changes, also into what to expect with different gestational ages. Jitteriness is something to always watch for. Can be caused by multiple things but most commonly it's usually hypoglycemia. Test a blood glucose if you suspect low sugar. Here in Canada

-fontanelles- anterior fontanelle is diamond shaped towards the centre top of the head. Familiarize yourself with the feel, and the size. Some are enlarged, some are small, some you can feel overlapping suture lines.. etc. The posterior fontanelle is a lot smaller and more triangle shaped. These should both be basically flush to the head. Bulging is a very bad sign- increased intracranial pressure. Sunken can indicate dehydration. Depending on delivery cephalohematoma, or caput. Learn the difference.

-ears- any skin tags or extra growth on the ears can be an indicator of kidney disease as the ears and kidneys develop at the same time in utero. Just something to be aware of. Low set ears may be seen in babies with down syndrome, FAS or other syndromes, this can be a sign further testing should be done. (the tops of the ears shouldn't be lower than the eyes)

-Mouth- you should assess the mouth with a gloved finger to ensure there is no cleft palate (not always visible in the lip! may be far back and no one else noticed it yet), and that a sucking reflex is present. If a sucking reflex is not present and the babies is not premature this can be a sign of a problem. Also assess for tongue tie (baby can barely lift tongue when crying, seems short in length when they try to lift it..) as this can cause issues with breastfeeding and very sore nipples for Mom if not noted! They usually snip them quickly here if the mom wants to breastfeed. It's very low pain, low vascular area, very quick, no sutures or anything required.

-Then you can start to unbutton the sleepers (I usually will count my respirations by having a hand on the belly now, but when I started I always made sure to do it with the sleeper open for easier visualization since it's faster than you will be used to). Respirations should be between 30-60. If they are below 30 and the baby is awake you would want to consider why (did mom have meds in surgery and baby is very fresh, does it need some narcan is it that depressed? etc) >60 can be normal if crying, but otherwise can be a sign of respiratory distress. Other signs of respiratory distress: nasal flaring, retractions (subcostal, substernal, intercostal, suprasternal, supraclavicular (last isn't easily seen in babies compared with children)), moaning, grunting, etc. Research into Transient Tachypnea of the Newborn (TTN) this is a common sign of respiratory distress in newborns that usually resolves in

-- Auscultate the chest, if the baby is not in any respiratory distress I will often get a heart rate first in case they start crying. If they are in distress I will listen to breath sounds first. When listening for heart rate it should be between 120-160. Sometimes may be around 110 if sleeping or sometimes even lower, but you should usually mention it to a senior nurse or a doctor if unsure as it may be abnormal. >160 may be normal with crying but otherwise is not. Murmurs can be heard at times, some people are better at others than catching them (it's not my forte sad to say ) its like a wooshing, almost like a sound of a breath sometimes when they aren't breathing. Breath sounds should be auscultated under the clavicular line bilaterally, under the armpits, and down under the nipple line if that makes sense. You may also listen in a pattern posteriorly, or depending on unit policy but this anterior approach is standard for us and our docs. The breath sounds should be clear and equal bilaterally. If one side is more decreased than the other, or crackles/wheezes present this is abnormal. (although if you are there immediately after birth you can often still hear some wetness as the amniotic fluid is not completely resorbed yet). Also look for equal chest expansion as they breathe.

-- Auscultate abdomen- listen in all 4 quadrants for bowel sounds, which should be present. Assess abdomen if it looks distended or scaphoid (scaphoid could be an indicator of congenital diaphragmatic hernia), also if you see any bulges/loops of bowel. Can gently palpate as well.

-Umbilical cord- should be clamped, with no discharge around the base, or foul odour. If it is very dry in appearance the clamp may be removed. Parents should be taught to clean around the cord once to twice a day with soap and water, and dry.

-Genitalia- Males- should not have hypospadius or other abnormalities. Females- more premature the inner labia are more prominent, but at term should be more covered by the majora. Both sexes ensure a patent orifice.

-Overall perfusion- This isn't necessarily done after genitalia but during the undressing process in general. They should be equally warm throughout the body, without for example, cold lower limbs and feet for no reason (i.e. if they were dressed). Brachial pulses should be easily palpable. Femoral are a little trickier to get used to but good to practice. These are the two main we focus on but your unit may be different.

-Reflexes- there are also some standard reflexes you should assess- sucking, grasping, plantar, babinski, etc.

-Temperature- I usually save the temp till the end cuz we do axillary and the babies hate it so I like to keep them calmer for the assessment lol. 36.5-37.3 is normal and we maintain a much tighter control in babies than adults!! I have had students before say the vitals were normal then 6 hours later tell me the temp was 36.1 :unsure: when I asked "So what was the temp earlier?" (I learned after that to always get the correct numbers instead of believing someone they were normal!) Babies have brown fat that they will burn off when their thermal regulation is not maintained and this can cause hypoglycemia, and obviously lead to weight loss as well. High temps could be signs of infection or may just be over bundled with clothes and blankets at times. (high or low temp could be sign of sepsis). Important note* If mom is GBS+, has unknown prenatal history, has been sick (i mean sick other than "morning sickness", i.e. influenza, etc) in pregnancy, any distress in labour, ETC (too many things to list but you get the idea...) be on higher alert for infection in the baby!

That got really long and is probably overwhelming, but when you actually do it, it is nice and quick :) I just like to try to explain to newer people how I do it and why.. If anyone finds that helpful I could do it for the mom's assessment if you like :cat:

Other things to look up: hyperbilirubinemia, direct and total bilirubin, coombs, cord gases, congenital heart defect screening, newborn screening..

Good luck!

Tanacious, MSN, RN, APRN, NP · Nov 11, 2015

That was awesome!!!! Thank you

missamelissy8 · Nov 11, 2015

Wow! Thank you so much, NurseStorm! I will certainly be referring back to this as I get going.

NurseStorm, BSN, RN · Nov 11, 2015

You're welcome Tanaciou and missamelissy8! I forgot to mention perfusion. In newborns sometimes you see acrocyanosis, where the hands and feet are somewhat cyanotic in appearance. This is a normal occurrence. But they should be pink and well perfused otherwise or this is an abnormal finding that needs to be further investigated (eg. pale, cyanotic throughout, or differing colour i.e.. well perfused in trunk but pale legs).

2. b) Mother assessment- Assess general mood and coping, provide support and encouragement as it is a difficult time with little sleep and it's always important to let them know how they are doing such a great job :)

- you can auscultate air entry, heart sounds and bowel sounds although a lot of maternity nurses don't do so, it's good practice for a new grad.

-VS of course

-Breasts- if breastfeeding assess nipples for any broken areas, bleeding, bruising etc. Emphasizing with mom the importance of ensuring a good latch and how to break the suction before removing baby if the latch is poor. Also assess the softness/firmness of the breasts and ask the mom if she's noticing a change/feels her breasts are heavier etc. If she is not breastfeeding, encourage her to wear a firmly supportive bra and avoid any stimulation of the breasts including letting hot water run onto them a lot in the shower, etc. This can help prevent milk from fulling coming in when they don't want it.

-Fundus- Fundal height should always be checked. Lay the patient flat on their back in the bed and palpate starting near the umbilicus. After delivery it is usually at or below the umbilicus and should continue to go down. If it is higher than previous assessments you need to figure out why and what is going on. If you can feel it at the level of the umbilicus (it feels kind of like a ball under the skin, for some women it is harder to feel than others - women with more adipose tissue usually) it is called u/0. If it is 1 finger below the umbilicus it is u/1 and so on. If it is a finger above the umbilicus its 1/u. Also assess for fundal tone. It should be firm. If its note, it's called boggy. Sometimes it may become firm with massage. If it is boggy you should always try to firm it up with massage. The funds should be central in the abdomen. If it is off to one side you need to ensure the patient is flat on her back and that she doesn't have a full bladder. Get her up to try and void if you are unsure. If a uterus is boggy, there may be clots inside, etc. and bleeding is definitely a risk here.

-Lochia/flow/bleeding- Assess bleeding. Hemorrhage is a risk so you always want to ensure you are educating the patient what to report (soaking more than a pad in an hour, saving clots larger than a toonie to be checked for tissue, etc). Rubra is the initial red bleeding, serosa is when it turns to more of a pinkish and alba is the final step, whiteish/yellowish, which you don't see in the hospital usually. The flow should be stopped by the 6 week checkup appointment, usually lasting 3-6 weeks. Make sure mom knows not to use tampons, pads only at this time.

-Perineum- inspect perineum for bruising, swelling, intactness of sutures if applicable, appearance of episiotomy if present, and also check if hemorrhoids are present (and if so get ointment for her). It is very normal for some swelling to be present. We have ice pack peri pads that help a lot with this. Just always be cautious with unilateral swelling, we have had a few hematomas form under the skin where it initially just looked like swelling but it quickly became quite large and very firm, not to mention the patient was in an immense amount of pain so we got the doc in, and he ended up having to take her to the OR to drain it (no colour change to skin). So just something to keep in mind! Also make sure she changes pads regularly, and does her sitz baths (or applicable hygiene method your hospital uses).

-Legs/feet- assess legs and feet for swelling/edema, and also check homan's sign (for DVT) by having patient flex foot out against your hand (sorry little hard to explain, google it if unfamiliar).

-VS- obviously same ranges for any other adult

-Hydration/Nourishment- If breastfeeding especially, these are veryy important. Encourage the mom to still take multi vits as the baby will draw from Mom and her bones even for it's nutrients if not supplied. Eating a good balance of healthy foods.. also drinking an adequate amount of fluids will help with milk production :)

Education- is a biggg thing on mother baby. Some topics to brush up on : the importance of DTAP vaccines for herself and close family members to help provide a "cocoon" effect of safety from pertussis (whooping cough). I really emphasize this as I mostly work as a meds nurse and it is a horrifying disease to see, and can be fatal, and there are current outbreaks, so very important to educate re: this!!

- importance of keeping sick people away from baby, and the importance of good hand hygiene for everyone who touches or is near baby

- "Back to sleep" and the prevention of SIDS (sleeping on stomach/side biggest risk factor, other biggest ones are sleeping in bed with parents, or 2nd/3rd hand smoke.Educate to all of these topics)

- Second hand/3rd hand smoke- preferably no smokers around baby at all but if not possible- definitely no smoking in the house or car!! Person should remove their coat/sweater they smoked in, wash hands, arms etc. and put a blanket over clothing if going to be holding baby. This smoke does increase risk of SIDS so make sure they are aware of this.

-Proper bathing technique for a newborn

-Formula preparation if applicable, and emphasizing not using powder until 6 months for safety (even though they say 0+ months..)

-Car seat safety- never add anything to the car seat- ie. strap paddings, head rests, cover that also goes under the back and around the straps. All of these just decrease the fit of the suit (As does large puffy clothes ,don't do it! Dress them when you get out, or put it on backwards after all buckled in. Discuss importance of keeping baby rear facing as long as possible for the seat and that it is very important for preventing neck/spinal cord/head injuries and this greatly outweighs any risk of leg injury which has been shown to be very smlll ( a lot of parents feel they have to turn because of their leg length). Also of having food or other objects in trunk secured so it's not possible for the baby to be hit with this in an abrupt stop or car accident.

-General safety- no hot liquids while holding baby, no bumper pads, extra blankets, pillow etc in crib. Not leaving baby unattended on changing table. Once a bit older, start having chemicals locked away, including cleaners, and baby proofing sharp edges, door and outlets, etc.

-Crying- watch the period of purple crying and educate yourself re: same. Our hospital implemented this and hopefully yours does too, but if not its still a great learning and teaching tool. Teach everyone re: shaken baby syndrome and the importance to know you can just set the baby down in a safe spot if you are getting frustrated and try to have a break, as it's normally people reaching their absolute peak of frustration that shake.

Hope this helps! It's meant as a guide so if I forgot to mention something, forgive me I'm very tired Tons more education areas you will cover with families. We have checklists we have to have completed on topics before they leave. These were just some off the top of my head lol.

NurseStorm, BSN, RN · Nov 11, 2015

I meant I mostly work as a PEDS nurse, damn autocorrect, lol

Tanacious, MSN, RN, APRN, NP · Nov 11, 2015

Thank you so much this is VERY helpful. I'm starting on MB and transitioning to L&D in 6 months. This is great!!!

NurseStorm, BSN, RN · Nov 12, 2015

Thank you so much this is VERY helpful. I'm starting on MB and transitioning to L&D in 6 months. This is great!!!

You're welcome Tenacious! I'm really glad you found it helpful! :)

ssrn13 · Nov 12, 2015

Don't sweat it! I've been a mom/baby nurse at a few different hospitals and the most orientation their new grads got was 4-6 weeks max before working the floor on their own. It is a totally different type of nursing than what you'll see on med-surg...postpartum is a lot a lot a lot of teaching and breastfeeding help with a quick pt turnover, so there's much to be done in a short amount of time. And babies are not just little adults, but it looks like @NurseStorm gave you some very valuable information! You will love being in maternity services :) Just don't be afraid to ask questions, it's a whole different ballpark!

Jburk1985 · Nov 12, 2015

Seriously best response ever! !! I posted a similar post recently and have been waiting to get reaponses. I found this thread and read your response and I am seriously taking away lots of valuable info!! Well put and we'll written!!!! I too recently accepted a position as a l and d nurse and I am coming from a neuro tele floor. I can't express how excited I am, but, I am terribly nervous and feel as if I am started allllll over. I am up for the challenge but definitely nervous. ...I have a couple questions that if you would like to answer would be great!!!

1. Cervical dilation- how to check mom's and what it feels like and how do I know if I am correct and do they let us practice?

2. Is there a possibility that I could deliver babies with out a dr? What is that like

Thanks !!