Chapters 13, 14, 16, 17, 18 Flashcards
afterpains (afterbirth pains)
Painful uterine cramps that occur intermittently for approximately 2 - 3 days after birth and that result from contractile efforts of the uterus to return to its normal involuted condition.
autolysis
the self-destruction of excess hypertrophied tissue
diastasis recti abdominis
separation of the two rectus muscles along the median line of the abdominal wall
involution
return of the uterus to a nonpregnant state after birth. Begins immediately after expulsion of the placenta.
lochia
vaginal discharge during the puerperium consisting of blood, tissue, and mucous
lochia alba
thin, yellowish to white, vaginal discharge that follows lochia serosa on approximately the tenth day after birth and may last from 2 to 6 weeks postpartum
lochia rubra
red, distinctly blood-tinged vaginal flow that follows birth and lasts 2 to 4 days
lochia serosa
serous, pinkish brown, watery vaginal discharge that follows lochia rubra until approximately the tenth day after birth.
pelvic relaxation
lengthening and weakening of the fascial supports of pelvic structures
puerperium
period between the birth of the newborn and the return of the reproductive organs to their normal nonpregnant state; fourth trimester of pregnancy
(typically 6 weeks, but time can vary)
subinvolution
failure of the uterus to reduce to its normal size and condition after pregnancy
At the end of the 3rd stage of labor, where should the uterus be located?
midline, approximately 2 cm below the level of the umbilicus.
12 hours after delivery the fundus can be palpated where?
the level of the umbilicus, possibly slightly above or below. After that fundus descends approximately 1 cm every day.
when should the uterus no longer be palpable abdominably?
2 week after birth
when should the uterus return to its pre-pregnancy state?
6 weeks after birth
What causes autolysis?
decrease in estrogen and progesterone after birth
lochial bleeding
Lochia usually trickles from the vaginal opening. The steady flow increases as the uterus contracts. A gush of lochia may result as the uterus is massaged. If the lochia is dark in color, it has been pooled in the relaxed vagina, and the amount soon lessens to a trickle of bright red lochia ( in the early puerperium)
non-lochial bleeding
if the bloody discharge spurts from the vagina, damage to a blood vessel may have occurred during birth. If so, some of the bleeding is not just normal lochial flow. If the amount of bleeding continues to be excessive and bright red, a vaginal or cervical tear may be the source.
Ovulation after birth
- can occur as soon as 27 days after birth in non-lactating women. With a mean time of 70 -75 days. menstruation typically resumes within 4-6 weeks.
- lactating women ovulation typically occurs at 6 months
postpartal diuresis
profuse diaphoresis often occurs, especially at night, for the first 2 or 3 days after childbirth.
Three postpartal physiologic changes protect the woman by increasing the circulating blood volume
- elimination of uteroplacental circulation reduces the size of the maternal vascular bed by 10-15%.
- loss of placental endocrine function removes the stimulus for vasodilation.
- mobilization of extravascular water stored during pregnancy occurs. In fact, by the 3rd postpartum day the plasma volume has been replenished as extravascular fluid returns to the intravascular space.
Transient anemia
after childbirth the total blood volume declines by approximately 16% from its predelivery value. Should return to normal within 8 weeks post partum
Normal WBC values afterbirth
it is not uncommon for values between 20,000 and 25,000
Temperature
Normal findings after Childbirth
Temp during first 24 hours may rise to 100.4F as a result of dehydrating effects of labor or a consequence of epidural anesthesia. After 24 hours the woman should be afebrile.
Pulse
Normal findings after Childbirth
Pulse returns to nonpregnant levels within a few days postpartum, although the rate of return varies among individual women
Respirations
Normal findings after Childbirth
Respirations should decrease to within the woman’s normal prepregnancy range by 6-8 weeks after birth.
Blood pressure
Normal findings after Childbirth
Blood pressure is altered slightly if at all. Orthostatic hypotension, as indicated by feeling of faintness, or dizziness immediately after standing up, can develop in the first 48 hours as a result of the splanchnic engorgement that may occur after birth.
Temperature
deviations from normal (and causes) after childbirth
a diagnosis of puerperal sepsis is suggested if a rise in maternal temperature to 100.4 is noted after the first 24 hours after childbirth and recurs or persists for 2 days. Other possible diagnoses are mastitis, endometritis, UTI, and other systemic infections
Pulse
deviations from normal (and causes) after childbirth
A rapid pulse rate or one that is increasing may indicate hypovolemia as a result of hemorrhage.
Respirations
deviations from normal (and causes) after childbirth
Hypoventilation (respiratory depression) may follow an unusually high subarachnoid (spinal) block or epidural narcotic after a cesarean birth
Blood pressure
deviations from normal (and causes) after childbirth
A low or decreasing blood pressure may reflect hypovolemia secondary to hemorrhage. However, it is a late sign, and other symptoms of hemorrhage usually alert the staff. An increased reading may result from excessive use of vasopressor or oxytocic medications. Because preeclampsia can persist into or occur first in the postpartum period, routine evaluation of blood pressure is needed. If a woman complains of headache, hypertension must be ruled out as a cause before analgesics are administered.
Varicosities after childbirth
Total or nearly total regression of varicosities is expected after childbirth
Lochia amounts
Scant (less than 2.5 cm) Light (less than 10 cm) Moderate (more than 10 cm) Heavy (one pad saturated within 2 hr) Excessive (one pad saturated within 15 minutes)
couplet care
one nurse, educated in both maternal and newborn care, functions as the primary nurse for both mother and neonate (also known as mother-baby care or single-room maternity care)
engorgement
Swelling of the breast tissue brought about by an increase in blood and lymph supplied to the breast, occurring as early milk (colostrum) transitions to mature milk, at approximately 72 - 96 hours after birth
uterine atony
relaxation of uterine muscles possibly leading to excessive postpartum bleeding and postpartum hemorrhage
warm line
a help line, or consultation service, for families to access, most often for support of newborn care and postpartum care after hospital discharge.
When are low risk complication mothers typically discharged?
24 - 36 hours after vaginal birth, often called early postpartum discharge, shortened hospital stay, or 1-day maternity stay.
What is the greatest risks associated with early discharge for the infant?
jaundice, feeding difficulties, infection, gastrointestinal obstruction, and unrecognized cardiac or respiratory problems.
Health protection Act of 1996
provided minimum standards for health plan coverage for mothers and their newborns. The plan required to allow the new mother and newborn to remain in the hospital for a minimum of 48 hours after a normal vaginal birth and for 96 hours after a cesarean birth.
Advantages of Early Postpartum Discharge
- Reinforces the concept of childbirth as a normal physiologic event.
- Allows shorter separation between mothers and other children.
- Extends a couple’s sense of control and participation beyond the birth itself.
- Capitalizes on the security of the home environment during the stressors of early parenting.
- Decreases unnecessary exposure to pathogens in the hospital environment
- allows beds on the maternity service to be used more effectively (greater turn around)
- Allows more time for mother, father, etc, to bond
- creates less disruption in the daily life of the family
- promotes active involvement of family and support person in assisting mother and newborn.
Disadvantages of early postpartum discharge
- complications (maternal or newborn) may go unrecognized)
- families may be or feel unprepared for the reality they face once the baby is at home.
- The mother is experiencing postpartum pain of discomfort
- the length of time for learning after the birth in the hospital setting is decreased.
- A vulnerability and crisis potential exists for both women and families.
minimum criteria for discharge of a healthy term newborn
- normal physical examination and clinical course
- vital signs WNL and stable for 12 hours prior to discharge
- Minimum of 2 successful feedings and able to coordinate sucking, swallowing, and breathing during feeding.
- urinated regularly and spontaneously stooled at least once
- risk of hyperbilirubinemia assessed and follow-up plans in place PRN.
- circumcision site without significant bleeding
- evaluated and monitored for sepsis
- maternal laboratory data reviewed
- infant blood type and coombs test results reviewed
- Hep B immunization administered
- Newborn hearing and PKU completed.
minimum criteria for discharge of the mother
- Knowledgeable, able, and competent to provide care
- risk factors assessed
- mother and family educated about safe environment
- plan in place for continuing medical care
- if discharged before 48 hr, follow-up within 72 hr by health care professional.
Lochia (days and which flow)
Day 1-3: rubra
Day 4-10: serosa
after day 10: Alba
The most common cause of excessive bleeding after birth is….
uterine atony
The two most important interventions for preventing excessive bleeding are…
- maintaining good uterine tone
- preventing bladder distention
Cause of uterine atony
the cause is not always clear, but it often results for retained placental fragments.
when weighing pads, 1 gram of blood equals….
1 mL
How often should pads be changed
with every void, or at least 4 times a day.
Scant
pad saturation
<2.5 cm
light
pad saturation
<10 cm
moderate
pad saturation
> 10 cm
Heavy
pad saturation
one pad saturated withing 2 hours
Excessive
pad saturation
one pad saturated within 15 minutes
Is BP a reliable indicator of impending shock from early hemorrhage?
No, more sensitive means of identifying hypovolemic shock are provided by respiration, pulse, skin condition, urinary output, and level of consciousness
Postpartum fatigue
more than just feeling tired; it is a complex phenomenon affected by combination of physiologic, psychologic, and situational variables.
It is encouraged that prenatal vitamins be taken at least….
6 weeks after childbirth, and throughout breastfeeding with women that choose to do so
Recommended calorie intake for the moderately active, non-lactating postpartum woman is..
1800 - 2200 calories a day
Recommended calorie intake for a lactating woman during the first 6 months is
2700 kcal/day
Recommended calorie intake for a lactating woman after the first 6 months
2768 kcal/day
After vaginal birth the mother should void within….
6 - 8 hours
* a volume of 150 mL is expected with each voiding
The ideal time to initiate breastfeeding is
in the first 1 - 2 hours
Rubella titer of 1:8 or >0.8
indicates the mother is not immune
Rubella vaccine facts
- does not pass through breast milk
- made from duck eggs (allergy alert)
- teratogenic - avoid pregnancy for 1 month after dose.
- if mother was given RhIg at hospital, titers need to be drawn in 3 months to see if she has developed rubella immunity as the RhIg suppresses immune response
Varicella vaccine facts
- administered before discharge in women without immunity.
- second dose is given at postpartum follow up visit
- teratogenic - avoid pregnancy for 1 month after each dose
RhIg is given….
at 28 weeks and within 72 hours after birth to prevent senitization in the Rh-negative woman.
en face
face-to-face position in which the parent’s and the infant’s faces are approximately 20 cm apart and on the same plane
acrocyanosis
peripheral cyanosis; blue color of hands and feet in most infants at birth that may persist for 7 to 10 days
brown fat
source of heat unique to neonates that is capable of greater thermogenic activity than ordinary fat; deposits are found around the adrenals, kidneys, and neck; between the scapulae; and behind the sternum for several weeks after birth.
caput succedaneum
swelling of the tissue over the presenting part of the fetal head caused by pressure during labor.
- disappears spontaneously in 3-4 days
cephalhematoma
extravasation of blood from ruptured vessels between a skull bone and its external covering, the periosteum; swelling is limited by the margins of the cranial bone affected (usually parietals)
- spontaneously resolves in 3 - 6 weeks
cold stress
excessive loss of heat that results in increased respirations and nonshivering thermogenesis to maintain core body temperature
erythema toxicum
innocuous pink papular neonatal rash of unknown cause, with superimposed vesciles appearing withing 24 to 48 hours after birth and resolving spontaneously within a few days.
habituation
psychologic and pysiologic phenomenon whereby the response to a constant or repetitive stimulus is decreased
jaundice
yellow color of skin due to increased level of bilirubin in body tissues
meconium
greenish black, viscous first stool formed during fetal life from the amniotic fluid and its constituents, intestinal secretions (including bilirubin), and cells (shed from the mucosa)
milia
small, white sebaceous glands, appearing as tiny, white, pinpoint papules on the forehead, nose, cheeks, and chin of the neonate.
mongolian spots
bluish gray or dark nonelevated pigmented areas usually found over the lower back and buttocks that are present at birth in some infants, primarily nonwhite, usually fading by school age.
sleep-wake states
variation in states of newborn consciousness from deep sleep to extreme irritability.
Two sleep states (deep & light), Four wake states (drowsy, quiet, alert, active alert, and crying)
surfactant
phosphoprotein necessary for normal respiratory function the prevents alevolar collapse (atelectasis)
thermogenesis
creation or production of heat, especially in the body
thermoregulation
control of temperature; a balance between heat loss and heat production
transitional period
period from birth to 4-6 hours later in which the infant passes through a period of reactivity, sleep, and a second period of reactivity
vernix caseosa
protective gray-white fatty substance of cheesy consistency covering the fetal skin
the neonatal period includes time from…
birth to day 28 of life
First phase of transition period
- up to 30 minutes after birth
- called first period of reactivity
- HR increases to 160-180
- respirations irregular with a rate between 60 and 80
- fine crackles can be present; audible grunting, nasal flaring, and retractions of the chest may be noted, but these should cease within the 1st hour of birth.
Second phase of transition period
- the newborn either sleeps or has marked decrease in motor activity.
- A period of unresponsiveness
- lasts 60 - 100 minutes
third phase of transition period
- second period of reactivity
- between 4 -8 hours after birth
- lasts 10 minutes to several hours
- brief periods of tachycardia and tachypnea
Meconium is typically passed when…
during the third phase of transition period; the second period of reactivity.
Initial breathing is probably the result of…
reflex triggered by pressure changes, exposure to cool air temperatures, noise, light, and other sensations related to birth process. In addition, the chemoreceptors in the aorta and carotid bodies initiate neurologic reflexes when PO2 falls, PCO2 rises, and arterial pH falls.
Normal respirations of newborn
shallow, irregular, 30 -60 breaths/min. Pauses of less than 20 seconds are normal.
Heart rate of newborn
- Average 100 - 160
- may accelerates as high as 175-180 when crying
- 85-90 when sleeping
- 170 or greater when awake.
PMI on newborn is found….
4th intercostal space and to the left of the midclavicular line
Average blood pressure of the newborn
SBP - 60 to 80
DBP - 40 to 50
Blood volume of newborn
85 mL/kg
- averages 300 mL and can increase by as much as 100mL depending on when cord is clamped.
Cord blood
Hgb, Hct, RBC, WBC, Plts
Hgb- 14-24 g/dL Hct - 44-64 % RBC - 4.8-7.1 million/mm3 WBC - 9,000 - 30,000 cells/mm3 Plts - 200,000 - 300,000 cells/mm3
Other things that can cause neutrophilia in newborn
prolonged crying, maternal hypertension, asymptomatic hypoglycemia, hemolytic disease, meconium aspiration syndrome, labor induction with oxytocin, surgery, difficult labor, high altitude, and maternal fever
Heat loss occurs by what 4 modes
Convection
Radiation
Evaporation
Conduction
Convection
the flow of heat from the body surface to cooler ambient air.
Radiation
is the loss of heat from the body surface to a cooler solid surface not in direct contact but in relative proximity.
Evaporation
the loss of heat that occurs when a liquid is converted to a vapor. A result a vaporization of moisture from the skin
Conduction
the loss of heat from the body surface to cooler surfaces in direct contact.
Voiding of the newborn
- 2-6 times per day during the first and second days of life
- 5 - 25 times per day after
- approximately 6-8 voidings per day of pale straw-colored urine are indicative of adequate fluid intake after the first 3-4 days.
“brick dust” in the urine
during the first week of birth a pink or orange stain in the diaper caused by uric acid crystals
Capacity of stomach of newborn
varies from 30 -90 mL
Blood glucose levels of newborn
50 -60 during the first several hours of birth
- 60 -70 by 3rd day of life
Simian line
palm crease that is found in Asians or infants with Down Syndrome
early signs of subgaleal hemorrhage
- boggy scalp
- pallor
- tachycardia
- increasing head circumference
telangiectatic nevi
“stork bites”
- pink and easily blanched
- found on eyelids, nose, upper lip, lower occipital area, and nape of the neck
nevous vasulosus
common type of capillary hemangioma
- raised, sharply demarcated, bright-or dark red, rough-surfaced swelling.
- strawberry hemangioma
nevus flammeus
a port-wine stain
polydactyly
extra fingers
syndactyly
fused fingers or toes
Average weight of male and female newborns
Male 3500 g
Female 3400 g
Average length
50 cm
Average chest circumference
30 - 33 cm
2-3 cm less than head circumference
state of modulation
ability to make smooth transitions between states
Newborn vision
can see as far away as 50 cm (2.5 feet)
- see best at 17-20 cm (en face)
- can detect color by 2 months
