Exam two class six: postpartum Flashcards
postpartum period
- after birth; traditionally seen as lasting 6-8 weeks but we are beginning to view this period extending to 12 months after birth.
key points of postpartum period
-Family centered and modeled on the concept of health
-Cultural beliefs and practices affect the birthing person and family
-Nursing care includes assessments to detect deviations from normal, comfort measures to relieve discomfort or pain, and safety measures to prevent injury or infection
common nursing interventions in postpartum period
-Preventing excessive bleeding, bladder distention, and infection
-Providing non-pharmacologic and pharmacologic relief of discomfort associated with afterbirth pain (cramping) episiotomy, lacerations, or breastfeeding
-Instituting measures to promote or suppress lactation
4th stage of labor
- first 4 hours after birth
- Maternal organs start to undergo readjustments to the non-pregnant state
nurses role in 4th stage of labor
-Identify and manage and deviations from normal
-Promote and support parent-infant bonding
-Prevent hemorrhage
-get breast feeding started
Assessments during the 4th stage
- Q 15 min x 4; Q 30 min x 2, Q 1 hr (dependent on institution)
-Vital signs
-Fundus, lochia, perineum, bladder
Focused Postpartum Assessment
General assessment-V.S., pain assessment, etc. +
BUBBBLEE
Breasts
Uterus
Bladder
Bowels
Bleeding
Legs
Episiotomy/laceration/c-section incision
Emotions
Physiological Changes and Assessments: vital signs
-HR: may see mild bradycardia r/t baroreceptor stimulation immediately PP, then returns to prepregnant states by 24-48 hours
-BP: increase days 4-6 then normalizes by 2-6 weeks
-Respirations: normalize within 24 hours (was fast in pregnancy)
-Temperature: return to normal within hours PP
1. Could be transient mild elevation (< 100.4 F) in 1st 24 hours
2. Could be transient temperature rise on 3-4th day
why is there a transient mild elevation in temperature in the first 24 hours
- general inflammatory reaction
- dehydration
- epidural
why is there a transient temperature rise on the 3-4th day after birth
- breast engorgement (full breasts from milk coming in = inflammation
While auscultating the heart of a postpartum patient what might you hear related to the physiological changes in pregnancy and PP?
systolic murmur from more blood volume
Physiological Changes and Assessments- cardiovascular
- Blood volume decreases 1000-1500 ml
-Diuresis: sweating at night 1st week PP
-Blood loss - Cardiac output: increases 60-80% immediately PP due to relief of the inferior vena cava obstruction and contraction of the uterus followed by rapid decline to prelabor values within 1 hour
-Pre pregnancy states by ~ 2 weeks.
Physiological Changes and Assessments- respiratory
-Immediate decrease in pressure on the diaphragm and reduction in pulmonary blood volume
-Rate back to normal within 2-3 days
when can someone start using estrogen based birth control
- when estrogen levels go down (6-8 weeks) or when your not breastfeeding
-What complication are you assessing for when auscultating the lungs?
- pulmonary emboli from estrogen
- pulmonary edema
Review of Systems/Labs- Head to toe approach with ROS
-Depression, anxiety, fatigue
-Fevers, chills
-Dizziness, syncope with ambulation
-Nausea, vomiting
-Headache, visual changes, RUQ/epigastric pain (pre eclampsia)
-Chest pain, palpitations
-Difficulty breathing, SOB- should resolve quickly (PE sign)
-Dysuria
-Pain with bowel movement
-Difficulty with moving/ambulation
HELLP labs
- check if concerned for preeclampsia
- hemolysis, elevated liver enzymes, low platelets
Review of Systems/Labs- potential
- Normally CBC, type and screen on admission
-Common to see WBC elevation 12,000-20,000 + in labor and postpartum- might mask infection
-Repeat CBC postpartum: H +H and WBC (normal to be high but assess other signs of infection) - HELLP labs
breast and nipple care: assessment and education for breast feeders
- alternate breasts
- no soap on nipples
- dont rip the baby off- use finger to delatch
- wear bra 24 hours a day without under wire
- assess for hard red lump on one side = mastitis
- are they soft or filling with milk (firmer) or very hard warm and engorged
when does mature milk come in
- 3-5 days after labor: before this its colostrum
what assessments and education can you provide for someone bottle feeding
- no nipple stimulation (not even warm water hitting the nipple)
- firm bra
- ice packs (or cabbage leaves) to reduce swelling when engorgement happens
latch score
-evaluates feeding effectiveness
-The higher the score the more effective the feeding
-By 12 hours of age the score should be >6
L=latch
A= audible swallowing
T=type of nipple
C=comfort (breast/nipple)
H= hold (positioning)
what do you determine the latch score off of
-Breasts- soft, non-tender, nipples are flat but intact
-LATCH Assessment
-Assistance required for positioning
-The baby was very sleepy and only held the nipple in his mouth, there were no audible swallows
uterus- involution
- Immediate postpartum: halfway between SP and U
- 1 hour PP: at U
- Next 6 weeks
-Cells atrophy and shrink
-Returns to non-pregnant location in pelvis by ~ 6 weeks
-Rate of descent: 1 cm per day until a pelvic organ at about 10 days
uterus after birth pains causes
- uterus contracting as its trying to get back down to normal position and site (oxytocin)
what causes more after birth pain/cramping
- breast feeding as it causes oxytocin to be produced
- the more babies you have
- bad menstrual cramps = bad cramps after birth
uterus after birth pain comfort measures
- NSAIDS (motrin and Ibuprofen) consistently
- alternate between Motrin and Tylenol
- lay on belly with pillow under uterus and this helps keep it contracted
- heating pads
fundus
- Must remain firm to control bleeding from the placental site
- Support lower uterine segment
- Assessment
1. Firm or boggy
2. Position in relation to umbilicus
3. Deviated to right or left of umbilicus - Documentation
causes of boggy uterus
- pieces of placental tissue
- clot
- lots of babies
- infection in uterus
- full bladder- can elevate uterus and cause it to not be contracted
what is a boggy uterus
- feels like wet sponge that compresses easily
what does a firm contracted uterus feel like
- grapefruit
how to document a fundal assessment example
- FF@U= fundus firm at umbilicus
- FF@U+1= fundus firm one finger above umbilicus
how to assess the uterus/fundus
- one hand above the symphysis and one hand above the umbilicus and cup around it
bladder
- Kidney function-returns to normal by 1 month
- Ureters and renal pelvices-hypotonia/dilation takes 2-8 weeks to normalize
- Transient increase in BUN and proteinuria-caused by breakdown of uterine tissue and slowing of GFR
- Decreased sensation to void– due to birth, epidural
-Urinary retention= increases risk of UTI and pyleonephritis
-Full bladder displaces uterus: Increased Bleeding
-Void within 6 hours after birth
-Assess for BS: Which patients is this especially important for?
- c SECTION PATIENTS
- No BS = illieus
bowels
-Decreased intestinal tone and motility- normal by 2nd week
-First BM: may not happen for first 3-5 days
-Hemorrhoids from pushing : Care
-Diet and Nutrition
diet and nutrition
- increased fiber and fluids
- if breast feeding: additional 500 calories per day
- can drink occasionally just feed the baby first then wait a few hours after to feed again
-Additional considerations with 3rd/4th degree lacerations
- this is a tear through the anal sphincter and mucosa so..
- make sure good peri care and not straining
- give stool softener
- dermaplast on perineum
hemorrhoids care
- hemorroid cream
- witch hazsel pad- tucks pad (can put in freezer)
- dermaplast (spray on perimeum)
bleeding/ lochia
- Consists of sloughed off necrotic tissue and blood
- Assessment includes
-Color
-Amount
-Clots
-Gushing
-Odor - Stages
-Rubra
-Serosa
-Alba
rubra
- first 3-4 days PP
- darker and larger
serosa
- pinkish/ brown
- less amount
- until 10 days PP
alba
- white discharge
- up until 6-8 weeks PP
Lochia amounts- documentation of amounts
-Scant
-Small
-Moderate
-Heavy
lochia amounts- too much/too big
> 1 pad saturated per hour
Clot/s > Egg/golf ball
- or if a lot of small clots that add up to the egg/golf ball size
scant amount of lochia
blood only on tissue when wiped or less than 1 inch stain on peri-pad within 1 hour
light amount lochia
- less than 4 inch stain on peri pad within one hour
moderate Lochia amoutn
- less than 6 inches stain on peri pad within one hour
heavy amount of lochia
0 saturated peri pad within 1 hour
Lochia
- from uterus
-Slow flow from vaginal opening
-More with uterine contraction, fundal massage, or breastfeeding
-Pooled lochia will be darker in color and coagulated
non-lochial
- not from uterus but could be from a tear that wasnt identified
-Contracted/firm uterus
-Constant flow
-Especially heavy, bright red
-What might cause this?
Extremities/legs- edema
- Initial increase from 3rd spacing and IV fluids that were given
- Education on relief measures for edema
relief measures for edema
- drink fluids
- elevate legs
- compression stockings
- get up and walk around
- will resolve within one week
Extremities/ legs- homans signs
- pain in calf with dorsiflexion of the foot
-What complication is this looking for: DVT
-look for Pain, streaks, heat, masses?
Extremities/legs: DTRs (deep tendon reflexes) and Clonus
- checking for hyperrefelxia and this is a sign of pre eclampsia
Vagina & Perineum changes
- Estrogen levels decrease
-Decreased lubrication/libido - Lacerations/Episiotomy
-Usually heals and suture dissolves by 6 weeks: May take longer for 3rd/4th degrees
-Pelvic rest: at least for 24 hours ideally 6 weeks
Vagina & Perineum- Evaluation of lacerations/Episiotomy
- have patient roll to side with one leg up to assess
-Redness
-Edema
-Ecchymosis
-Discharge or Drainage
-Approximation
when can you have intercourse again
- when ready emotionally
- when no bright red bleeding
- when can stick a couple fingers up there with no pain
Perineal Care- general hygiene
-Peri bottle filled with warm water and spray from front to back after each urination
-Wiping/patting dry from front to back
- change pad after every void
peri care- comfort measures
-Ice pack for 24 hours
-Tucks pad
-Dermoplast spray
-Witch hazel pads
-Sitz bath 2-3 times daily
C-section Incision
- Types of skin closure: staples will be removed before you go home and steri strips will be applied
- Dressing for first 24 hours (removed when you take first shower): Assess if it is clean and dry
- Wound:
-Redness
-Ecchymosis
-Edema
-Discharge
-Approximation
- fundal assessment is the same
Emotions/Bonding: -Signs of positive bonding/attachment
- cares for baby
- ask questions about baby
- hold the baby in the “en face” position, touches newborn
- talks, coos, signs to the baby
- names the baby
Emotions/Bonding: how can we foster this
- early contact, skin to skin
- rooming in
- assit/encourage parents to perform care
- allow partner/family to stay
- education
- support with feeding
- identify risk factors
the blues
Most common form of postpartum mood change
- may be dramatic
the blues onset
First few days, resolves by 2-3 weeks
the blues causes
Fatigue
Uncertainty
Frustration
Hormonal fluctuations
Unrealistic expectations
Lack of sleep and support
the blues nursing tx
Rest, support, reassurance
how to asses for postpartum depression
- Edinburgh Postnatal Depression Scale (EPDS) = Self-administered 10 item tool
Edinburgh Postnatal Depression Scale (EPDS)
-Developed in 1987 to be used by primary care providers to identify pregnant/PP patients at risk for post natal depression
-Early identification of depression is crucial to the well-being of patient and baby
Self-administered 10 item tool for EPDS
- Asked to select the response that best matches how they have felt in the last 7 days
-Total points possible is 30 which represents the most severe symptoms - Administered
-Prenatally: at initial visit, 28 weeks
-Postpartum: prior to d/c from hospital, at 2 and 6-week postpartum visits, prn
Positive EPDS screening
- Different scoring thresholds based on population being screened
- Prenatal
-First trimester > 11
-Second/third trimesters > 10 - Postpartum- >/= 13 considered positive screen
-Answers yes to question #10—”The thought of harming myself has occurred to me…”
-Clinical judgement
-Other factors that may influence results:
*Understanding of the language
*Fear of consequences if depression is identified (stigma, etc)
*Different emotional reserves
Vaccinations
Rubella non-immune: give MMR
Varicella vaccine if non immune
Rh negative mom with Rh positive fetus: Rhogam 300 mcg within 72 hours
Tdap if they didn’t get it in the pregnancy
COVID
discharge teaching
- Planning and education for discharge should begin at first interaction after birth and continue throughout the hospitalization
- All patients should be educated on:
-Comfort measures
-Rest
-Nutrition
-Hygiene
-Baby Care
-PP expectations
-Pelvic rest - Warning signs for postpartum complications:
warning signs of postpartum complications
PE
Cardiac disease
HTN
Hemorrhage
DVT
Infection
Postpartum depression
Be cognizant of cultural beliefs
uterus after birth pains causes
-Causes: usterus contracting.
education when DC: call 911 if
- pain in chest
- obstructed breathing or shortness of breath
- seizures
- thoughts of hurting yourself or someone else
education when DC: call your healthcare provider if you have `
- bleeding, soaking through one pad/hour, or blood clots the size of an egg or bigger
- incision that is not healing
- red or swollen leg that is painful or warm
- temperature of 100.4 or higher
- headache that doesnt get better even after taking medicine or bad headache with vision chnages
leading cause of perinatal M&M
- infection
- hemorrhage
- HTN
- Emboli
timing of postpartum hemorrhage
- early or primary: first 24 hours after birth
- late or secondary: > 24 hours after birth up to 6 weeks PP
dx for pph
- 1000 ml or more of blood loss
Normal amount of blood loss with vaginal/cesarean births
- < 1000 ml
what are the 4 T’s of PPH
- Tone
- Tissue
- Trauma
- Thromboembolic disorders
tone
- anything that causes the uterus to grow alot
- too full, too fast, too long, too much pitocin
- meds that stop CTX’s: magnesium sulfate which is a muscle relaxant
- grand multip
- infection
- Atony= #1 cause
tissue
- retained placental tissue pieces
- these cause the uterus to not be able to contract down as well
trauma
- episiotomy, lacerations, sulcus, cervical, uterine rupture, hematomas, uterine inversion
what is a sulcus
- tear along the floor of the vagina
treatment of hemorrhage- Atony
- anticipate
- fundual massage, bimanual compression, 2nd iv line, empty bladder
- medications to contract the uterus
- initiate breastfeeding when the mother and baby are safe
- pain meds
who do you anticipate atony in
- someone who had: long labor, large baby, history of PPH)
when do to the fundal massage
- once the placenta is out
- notice if it is firm with minimal bleeding or boggy (soft) with bleeding
medications for PPH caused by atony
- pitocin
- cytotec
- methergie
- hemabate
- TXA
pitocin in treating hemorrhage
- 10 units IM in leg OR 10-40 units in 500 ml NS wide open
- give after birth of baby or placenta
cytotec in treating hemorrhage
- 800-1000 mcg SL or rectally
- helps increase uterine tone
- can cause: shivering, fever, diarrhea
methergine for treating hemorrhage
- 0.2 mg IM Q 2-4 hours
- second line
- contraindicated in HTN
- effects the upper and lower segment of the uterus so if have clots helps contract them down and out
- consider 0.2 mg PO Q 6 hours x 4 doses as a maintenance dose once pPH is controlled or for a patient with retained products with manual sweep
hemabate for treating hemorrhage
- 250 mcg IM Q 15 minutes x3. max 2 mg
- contraindicated in asthma
- causes explosive diarrhea pretty quickly so give with immodium
TXA for treatment of hemorrhage
- 1 gram IV in 50 ml NS over 10-20 minutes or 1 gram PO
- initial dose has to be given within 3 hours of birth
- can give a 2nd dose 30 minutes later up to 24 hours
- decreases bleeding by inhibiting the breakdown of clots and fibrin
why does initiating breastfeeding help treat hemorrhage
- body will produce oxytocin which helps contract uterus down
why give pain meds in hemorrhage treatment
- you are giving all these meds to make the uterus contract down and work harder- can be painful and the contractions can feel like labor
treatment of hemorrhage- retained tissue
- 2nd iv
- prep patient/family
- assist with US (to look at uterus and see if there is retained products or clots) and manual removal
- pain meds if no epidural: IV fentanyl or nitrus
- prophylactic abx: probably will be given 2 g ancef (cephazolin)
- possible surgery (D&C) if cant get out the entire placenta or if can get all the pieces- needs to be NPO
when might you need a hysterectomy with retained tissue causing a hemorrhage
- accreta: least severe- may not need hysterectomy: placenta is growing into the endometrium linning
- percreta: placenta is embeded inside the muscle
- increta: placenta grows through the uterus and into the organs
what is retained tissue
- piece of membrane or extra lobe which doesn’t allow the uterus to contract down as well and puts the women at risk for PPH or delayed PPH
manuel sweep vs manual removal
- sweep: if pulling out remaining products
- removal: if removing the whole placenta
could a hemorrhage from retained tissue happen after a termination
- yes- but is rare
- if D&C: most likely not
- if medicated induced: more likely
how does the provider remove the retained tissue
- takes gloved hand and inserts it inside the cervix and into the uterus and then uses that hand to move any pieces along uterine wall
treatment of hemorrhage: trauma
- more common with operative vaginal deliveries- assisted deliveries (forceps and vacuum)
- lacerations: have the suture, anesthetic, sterile gloves, good light, and sponges ready
- hematomas
hematomas causing hemorrhages
- inside the vagina caused from lacerations that were not repaired right or pressure against the area that kept bleeding and the blood started to develop under the skin
- 500 ml can accumulate in the potential space of the iliorectal fossa
- may occur before any vulvar bruising or discoloring noted by RN
- may show S/S of hypovolemia out of proportion to estimated blood loss: dizzy, faint, pain and pressure against rectum feeling like they need to push
- pain is disproportional to reported perineal laceration and repair
treatment of hematomas
- packing
- ice
- watchful waiting
- evacuation and litigation if “bleeder” or if too big. usually done in OR need to be NPO
uterine inversion causes
- grand multiparity: ligaments are not very tight so harder to hold the uterus inside
- mismanagement of 3rd stage: delivery of the placenta and if the provider pulls to much on the cord and it isnt detached from the placenta
unlukcy
tx of inversion of uterus
- put it back into the vagina
- emergency
thromboembolic disorders
- identify them: of there is no clotting on the floor or in the bucket= problem
- anticipate: specific factors ordered for labor and low platelets
code white
- if no other hemorrhage interventions work or VS change (late sign of hypovolemia) call a code white
- all treatment already mentioned plus:
1. support team: interventional radiology, additional OB, blood bank, lab, anesthesia
2. uterine balloon tamponade
3. arterial embolization
4. uterine suturing techniques
5. ligation of arteries
6. hysterectomy - sometimes this isnt enough and you still have maternal death
pregnant person and blood loss
- have to loose more than non pregnant patient because of the 50% blood volume increase in pregnancy
- feel blood loss later than non pregnant
bakri balloon
- placed inside the cervix and into the uterus and then you insert NS into it and this will put pressure on the uterus to help it contract down
- can leave in for up to 12 -24 hours
late postpartum hemorrhage
- after 1st 24 hour up to 6 weeks PP
- can wake up in bed full of blood
- often very sick due to delayed treatment and in the ICU
causes of late PPH
- atony
- retained fragments (tissue)- most common
- infection
- unknown
treatment of late PPH
- IV access
- US of uterus to see if it is empty
- D &C
- Meds: methergine, cytotec, pitocin, hemabate
- Abx
- litigation of uterine arteries
- hysterectomy
uterine infection: endometritis
- most common type of PP infection
- begins as localized infection at the placental site then can spread to include the whole endometrium
- if not treated can lead to septicemia and maybe maternal death
risk for endometritis
- c-section: since manually removing placenta and uterus
- PROM
- multiple cervical exams
- FSE: electrode placed on top of fetal head if cant get fetal monitoring on abdomen
- IUPC: intrauterine pressure catheter inside the uterus
- vacuum/forceps
- DM
- intraamniotic infection during labor
- pre existing infection
signs and symptoms of endometritis
- maternal fever
- chills
- increased pulse
- uterine tenderness
- foul smelling lochia
treatment of endometritis
- abx
- D & C if have retained tissue
- oxytoxics
untreated endometritis
- can become pelvic cellulitis, septic pelvic thrombophlebitis, frank septicemia, death
infection: UTI causes
- catheterization during labor or after delivery
- inability to urinate PP
Treatment of UTI
- UA collection for analysis and looking for positive nitrates
- C + S= urine culture and sensitivity
signs of UTI
- burning with urination
- kidney/back pain
- fever
- superpubic pain
medication for UTI
- abx
UTI could lead to what if not treated
- pyelonephritis
- can lead to gram negative speticemia
- may require hospitalization and IV instead of oral abx
- may disrupt breastfeeding and may need to pump and dump
breakdown of episiotomy/laceration causes
- poor tissue (DM, poor nutrition, genetic)
- poor technique of sutures
- infection causing more breakdown in tissue
- unknown
s/s of breakdown of episiotomy/laceration
- ” i feel like I am gaping open”
treatment of breakdown of episiotomy/laceration
- abx
- repair within 1st 3 days
- if not within first 3 days: debriedement and healing by secondary intent
Worst case with breakdown of episiotomy/laceration
- necrotizing fasciitis (group A sterptococcus “flesh eating”)
infection: cesarean incision causes
- poor tissue (diabetes, obesity causing abdomen that falls over incision = moisture build up and increase chance of infection
- poor technique
- unknown
treatment if cesarean incision infection
- depreidement
- irrigation
- packing
- healing by secondary intention
- ABX
- prevent extra moisture with patient who is obese by using peri pad over incision. instruct them to keep it dry
caution with cesarean incision
- be alert for paralytic ileus
- make sure they are getting up and passing gas
- chewing gum can help get the bowel moveing
infection: mastitis
- stasis of milk in milk ducts of breasts then there is a trauma that occurs to the nipple from Breast feeding or pumping then the bacteria is introduced into the system from the babies mouth
diagnostic s/s of mastitis
- high fever > 102
- breast tenderness
- redness over clogged and infected lobule
- feel very sick- flu likee
treatment of mastitis
- abx for staph aureus which is usually the cause ( dicloxicillin)
- continue to breastfeed as this can help expel the built up milk
if you dont treat mastitis what can it turn into
- abscess
- requires Incision and draining
- D/C breast feeding until healed
- abc
- may need to pump and dump
the blues onset
- first few days
- resolves by 2-3 weeks
- can be quite dramatic
- most common form of Postpartum mood change
causes of the blues
- fatigue
- uncertainty
- frustration
- hormonal fluctuations: decrease in estrogen and progesterone and increase in prolactin
- unrealistic expectations
- lack of sleep and support
treatment for the blues
- rest
- support
- reassurance and empathy
- tell them: sleep when baby sleeps, let them know this is common, and give them advice for when they are upset or overwhelmed (put baby down in safe place and walk away and breathe)
postpartum depression onset
- any time in the first year (usually after 2-3 weeks)
- will be crying all the time, not bonding well with the baby, cant get out of bed
postpartum depression risk factors
- Hx of any depression of hx of PPD
- primips (first time mom)
- lack of social support (DV, poverty)
- complicated labor/delivery causing PTSD
- adolescents
causes of postpartum depression
- hormones
- chemical imbalances
- genetic predisposition
- lack of sleep
- role transition
treatment of PPD
- you need to ask
- support group
- anti depressants
- help at home
- sleep
- reassuracne that she isnt alone
- follow up @ 2 weeks
post partum anxiety onset
- any time in the 1st year (after 2-3 weeks)
postpartum anxiety risk factors
- Hx of anxiety or PP anxiety or other mental health problems
- family history of anxiety
- previous pregnancy or infant loss
- complicated labor/delivery
- Hx of thyroid disorders
symptoms of post partum anxiety
- fear
- worry
- stress
- intrusive thoughts like thinking constantly about safety and the baby
- fear will do something wrong
- restlessness
- overwhelmed
- on edge
- restless sleep
- panic attacks
causes of post partum anxiety
- hormones
- chemical imbalances
- genetic predisposition
- lack of sleep
- role transition
tx of postpartum anxiety
- CBT/ other therapies
- anti anxiety meds
- help at home
- sleep
- support
- follow up @ 2 weeks
risk factors for postpartum psychosis
- Hx of bipolar, OCD, stress
onset of postpartum psychosis
- as early as day 3 PP
clinical features of postpartum psychosis
- sleep disturbances
- depersonalization
- psychomotor disturbances
- euphoria with hallucinations/delusions (may include SI and homocidal ideation)
treatment of postpartum psychosis
- hospitalization with baby but never left alone
- antipsychotic meds
- therapy
AAP recommendations for BF (breastfeeding)
-Exclusive breastfeeding for first six months
-Introduction of solids and other fluids at six months
-Continued breastfeeding until at least 12 months
Breastfeeding Advantages- baby benefits
-Less- GI problems, SIDS, allergies/asthma, diabetes, childhood cancers, obesity, infections
-Better cognitive development, higher IQ
Breastfeeding Advantages- mother benefits
-Promotes uterine involution, decreased risk of postpartum hemorrhage, enhanced pregnancy weight loss, bonding, decreased risk of breast cancer, decreased stress
Breastfeeding Advantages- financial
-Save on average $400/year for infant medical costs
-Cost of formula, bottles, etc.– On average $3-5/day for formula
Breast milk production
-Breast divided into 15–20 lobes
-Separated by fat, connective tissue
Physiologic and endocrine control of breast milk
- Estrogen, progesterone, prolactin:
-After delivery sudden drop in estrogen and progesterone stimulate secretion of prolactin from anterior pituitary and breast milk is produced - Oxytocin- secreted by posterior pituitary and responsible for milk ejection, “Let down”
Breast Milk Composition- casein and whey proteins
- Casein and whey proteins
-Whey predominant protein in human milk: 60:40 whey/casein ratio
-Easily digested
-More frequent feedings - Casein predominant in cow milk: 20:80 whey/casein ratio
- Less easily digested, forms curds
Breast Milk Composition- vitamins
-Fat soluble – A, D, E, K
-Water soluble - Bs, C
Breast Milk Composition- carbohydrates
-other main source of energy
-40% of calories in diet
-Primary carbohydrate is lactose
-Formulas: All lactose, lactose/corn maltodextrin
Breast Milk Composition- fats
-Approximately 50% of calories
-30–50 gm/liter of human milk: Fat content variable
Breast Milk Composition- immunoglobulins
Infection prevention
Breast Milk Composition
-Casein and whey proteins
-Vitamins
-Carbohydrates
-fats
-Immunoglobulins
Lactogenesis Stage I
- Colostrum (“Liquid gold”): first 3-4 Days
-Clear yellowish fluid
-Production begins in mid pregnancy - Small amount to allow the baby to learn to suck, swallow and breathe at the same time
- High in protein, immunoglobulins & minerals
- High protein level facilitates bonding bilirubin
- Acts as a laxative to: Pass meconium, Pass bilirubin
Lactogenesis Stage II
-“Milk coming in” phase: day 3-5 to day 10
-Breast milk continues to ‘mature’
-“Engorgement” likely to occur at this point
Causes of engorgement
-Response to hormonal changes
-Milk production
-Engorged blood vessels & lymphatic swelling
symptoms of engorgement
Full, hard, tender, warm breasts
Lactogenesis Stage III
- Mature Milk: Day 10
-Fat content of BM increases as neonate feeds - Foremilk: bluish-white (60% skim & 30% whole milk)
-Lactose, protein & WS vitamins - Hind milk: cream (5%)
-For calories
-Occurs 10-20 minutes in to feeding
-Why you must try & ‘empty’ breast q feeding
Supplements for BF
-Use only when medically indicated
-Some facilities have donor milk programs- two milk banks in CO
-Try to avoid artificial nipples:
Finger feed
Cup feed
Pacifiers
-For non-nutritive sucking
-Use after breastfeeding is well established (2-4 weeks of age)
Cultural considerations for BF
Hispanics prefer to formula and breastfeed
Nursing Roles in Breastfeeding
- timing
-assessment
-Support and Assist with positioning, latch, etc.
-Education- Reinforcement and repetition
-Lots of patience
Timing of BF
-First feeding during first period of reactivity
-Feed on demand or at least q 1.5-3 hours
Assessment of BF
- Feeding effectiveness
-LATCH score at least once a shift
-Low LATCH scores require intervention with Lactation Consultants - Breast structure and signs of problems
latch score
-Assessment of the effectiveness of the breastfeeding session
-The higher the score the more effective the feeding
-A score of 6 or higher by 12 hours of age is expected
-Lower scores-
Assess every feeding until >6
Assist and provide education
Consult a Lactation Specialist for evaluation, assistance, and intervention
Latching Newborn
- Nose to nipple- goal is to achieve an asymmetric latch- bottom jaw further onto areola than top jaw
- Stimulating rooting reflex- stroke nipple downward over bottom lip
Newborn will open wide with tongue down and will drop head back- the baby in this photo needs to open wider before being placed on breast
Once the mouth is open wide the BABY is brought to the breast, not breast to baby
Breast/Nipple Assessment
-Need to assess type of nipple (flat, everted, inverted)
-Cracked, bleeding, red– signs of inappropriate latch
Breast Shells
-Can help to cause flat or inverted nipples to protrude
-Begin use in late 3rd trimester
-These may be used to assist with latching but it is important to work with lactation before and during use of the breast shields.
-With continued use the milk supply can be reduced by 50% or more.
-These can be beneficial for extremely damaged nipples or flat nipples
Positioning
- Cradle hold
- Cross cradle hold, modified cradle, or across the belly cradle hold
- Football
- Side-lying
Cross Cradle Hold
-Mother to sit in upright position using good body alignment
-Pillows for support
-Baby placed on lap- belly to belly or baby in side-lying position with baby’s nose at nipple
-Head supported with hand opposite breast she is feeding on positioned on nape of neck
-Breast supported by hand on same side
Cradle Hold
-Mother to sit upright using good body alignment
-Baby placed on lap belly to belly position, side-lying with nose at nipple
-Head cradled in crook of arm on the same side as the breast
-Breast is supported by hand opposite breast she is feeding on
Football Hold
-Mother to sit upright
-Pillows used to raise baby’s body to breast level
-Baby’s bottom rests near mother’s elbow and body turned slightly to face breast
-Head supported at nape of neck and body is supported by mother’s arm
-Breast is supported with hand opposite breast she is feeding on
Side-Lying
-Mother lies on side
-Pillows support head and back, between bent knees
-Baby placed in side-lying position next to mother, belly to belly, nose lined up with nipple, pillow or roll placed behind back
-Breast supported by hand opposite breast she is feeding on (top arm)
how to hold the nipple
-C-hold or Sandwich hold
how not to hold the nipple
-Scissors Hold
-Scissors hold is discouraged because moms are unable to keep fingers at least 1 ½ inches from base of aerola
Signs of Effective Breastfeeding
-Infant nursing ≥8 times in 24 hours
-Mother can hear infant swallow
-Mother’s breasts soften after feeding
-Number of wet diapers increases: 6-8 wet diapers a day beginning on day 5
-Infant’s stools begin to lighten and transition from meconium to breastfeeding stools
comfort measures for engorgement
-Empty breasts q2h; preferably by the baby
-Ibuprofen, massage, ice
-Not recommended to pump/hand express milk between/ after feedings causes increased milk production and worsens engorgement
-If engorgement causes nipples to flatten and become hard use breast pump/hand expression just to soften nipple to allow latch
-Cabbage leaves no longer recommended due to risk of food borne illness
comfort measures for Cracked, bleeding, bruised nipples are signs of poor latch
-Lansinoh cream- no need to wash off
-Gel pads- “soothies”
-Nipple Shields until nipples are healed
Normal bilirubin conjugation and excretion
-RBC breakdown produces UNCONJUGATED bilirubin (fat soluble)
-Transported to liver by Albumin
-Liver converts to water soluble bilirubin (CONJUGATED)
-Conjugated bilirubin excreted into bile duct and then into intestines
-Excreted via urine and stool
things that increase newborns risk for Hyperbilirubinemia
- Short ½ life of fetal RBCs (70-90 days) = Increased red cell volume
- More bilirubin produced
- Decreased conjugation due to lack of glucuronyl transferase
- Lack of gut bacteria & low GI motility causes increased reabsorption of bili
Hyperbilirubinemia incidence
-50% of term neonates
-85% of preterm infants
Hyperbilirubinemia modifiable risk factors
-Delayed/ineffective feedings= dehydration
-Excessive weight loss
-Prematurity
-Rh incompatibility (give RhoGAM)
-Use of oxytocin
-Infections
-Hypoxia/asphyxia
-Birth trauma: forceps or vaccum assisted
-Maternal diabetes
Hyperbilirubinemia non modifiable risk factors
-Male gender
-Sibling with jaundice
-Race: Asian, Native American, Greek
-ABO incompatibility
Hyperbilirubinemia types
Physiological
Pathological
Breastfeeding
Breast milk
how does Hyperbilirubinemia progress
- head to toe
- toe to head regression
Breast Milk Jaundice
-Occurs 3-5 days after mature milk which comes in 3-5 days after birth so we are talking 6-10 days of life
-May last several months but peaks around 2-3 weeks
- occurs LATER ON
breast milk jaundice causes
- composition of breast milk:
-Increased free fatty acids in some breast milk
-Free fatty acids compete with bilirubin binding sites on albumin
-Inhibits conjugation: less bilirubin taken to liver - Increased reabsorption of bilirubin in GI tract
breast milk jaundice tx
-Continue to breastfeed if bili levels <20mg/dl
-Interrupt breastfeeding and do formula feeding for few days if bili 20 mg/dl
total serum bilirubin in breast milk jaundice
- usually peaks at 5-10 mg/dl by 2-3 weeks
breastfeeding jaundice causes
- Appears in first few days (OCCURS EARLY ON)
- Ineffective breastfeeding causing dehydration
- Dehydration
- Delayed meconium stool passage since not getting colostrum which is good laxative: One good meconium stool reduces bili level ~1 mg/dl
tx of breastfeeding jaundice
- Support effective breastfeeding: encourage early effective feeds and do latch assessment
-Frequent feedings
-Lactation consultation - Promote stooling
-Colostrum is a great laxative - Avoid supplementation: formula not digested as well so wont feed as much
Physiologic Jaundice
-Normal adaptation
-Appears after 24 hours
-Peaks around 3-5 days
-No longer apparent by 14 days
causes of Physiologic Jaundice
-Increased breakdown of fetal RBCs
-Impaired conjugation of bilirubin- lack of glucuronyl transferase
-More bilirubin reabsorbed by GI tract
Pathologic Jaundice
-Appears within the first 24 hours
-Lasts longer than 1 week
causes of Pathologic Jaundice
- ABO incompatibility
- Hemolytic disease of the newborn
- Maternal disease processes
1. Diabetes
2. Intrauterine infections
3. Drugs-sulfa, salicylates, novobiocin, diazepam, oxytocin
total serum bilirubin in pathoilogic jaundice
- > 0.2 mg/dl/hr (>95th percentile)
-rises >5 mg/dl/day - rise is quicker and goes above 95th percentile
total serum bilirubin in physiologic jaundice
rises </= 5 mg/dl/day
Hyperbilirubinemia Treatment
Treatment guidelines based on gestational age, hours old, and risk factors
phototherapy
-Most widely used treatment
- helps break bilirubin down into conjugated form
-Blue lights most effective
physiology
-Converts to water soluble form
-Excreted via urine and stool
Exchange transfusion- rarely used
- Replaces 85% of RBCs if phototherapy is not working or antibodies are causing the breakdown
-Corrects anemia
-RBCs with maternal antibodies removed
-Other hemolysis toxins removed - Used when phototherapy ineffective or severe hemolytic disease present
Care of Neonate Receiving Phototherapy
- Positioning of lights: 45-50 cm from infant
- Maximum exposure
-Frequent position changes: back, belly
-Naked except for diaper
-Limit time out and dont block light by leaning in front of- only out to feed - Monitor
-Vital signs-especially temperature
- watch skin for rashes
-Intake and output: can cause loose stools=dehydration
-Side effects
-TSB levels- should drop 1-2 mg/dl within first 4-6 hours - Protect eyes with mask
side effects of phototherapy
Loose stools, dehydration, hyperthermia, lethargy, rashes, impaired bonding, eye damage
Hyperbilirubinemia assessment
-Blanch skin beginning on face and moving down body
-Consider lighting of room= natural light is best
how to decrease the risks of Hyperbilirubinemia
- Prevent cold stress
- Promote early feedings
- Monitor stools
lab testing for Hyperbilirubinemia
- Cord blood typing for newborns of mother’s with O blood types
- Direct Coombs test (DAT): antibody testing to see if causing hemolysis of RBC
- Total serum bilirubin (TSB): Visually apparent jaundice=TSB of 4-6 mg/dl
- Transcutaneous bilirubin level
Hyperbilirubinemia Complications
- Kernicterus (“yellow nucleus”) in brain tissue
- Preventable
- Chronic and permanent sequelae of untreated hyperbili
early stage of Hyperbilirubinemia Complications
-Extreme jaundice
-Absent startle reflex
-Poor feeding or sucking
-Extreme sleepiness (lethargy)
mid stage of Hyperbilirubinemia Complications
- High-pitched cry
- Arched back with neck hyperextended backwards
- Bulging fontanel (soft spot)
- Seizures
late stage of Hyperbilirubinemia Complications
-High-frequency hearing loss
-Mental retardation
- Muscle rigidity
-Speech difficulties
-Seizures
-Movement disorder
ABO Incompatibility
- Type O blood contains anti-A & anti-B antibodies (IgM)= this is normal and not caused by exposure
- If enter fetal circulation at birth of blood types A or B or AB cause clumping of RBCs
incidence of ABO incompatibility
- Hemolytic disease of the newborn (HDN) occurs in 10% of these cases of incompatibility
Consequences of HDN
- Rapid destruction of fetal RBCs
-Hyperbilirubinemia
-Anemia
-Death
*no available prevention of HDN
Rh Antibodies
- Rh positive blood types= D antigen
- Rh negative blood types= No D antigen
-With exposure to Rh positive blood anti-D antibodies are produced (IgG antibodies) - First Rh positive fetus: Risk of Rh sensitization 2-16%
-Maternal immune system not adequately provoked - Second Rh positive fetus: Anti-D antibodies produced and cross placenta
-Fetus affected by hemolytic disease
- Prophylactic RhoGAM prevents Anti-D antibody formation
Rh Sensitization
- Anti-D antibodies cross placenta and attach to fetal RBCs
-Cause hemolysis of fetal RBCs
-complications: Erythroblastosis fetalis or Hydrops fetalis-most severe form
Erythroblastosis fetalis
-Anemia
-Jaundice
-Increased immature RBCs
-Death
Hydrops fetalis
-Severe anemia
-Multiple organ system failure
-Cardiac decompensation
-Generalized massive edema
-Death
Rh Sensitization Prevention- rhogam
- Made from plasma
- Prevents production of anti-D antibodies
- Provides protection for approximately 12-14 weeks
- Prophylactic administration in Rh Negative woman:
1. At 28 weeks in every pregnancy
2. Miscarriage/abortion
3. Other—amniocentesis, abdominal trauma, ECV, when mixing suspected
4. After delivery if fetus is Rh Positive
-Decreases risk of hemolytic disease in fetuses in subsequent pregnancies
-Once antibodies form RhoGAM is no longer effective
Late Preterm Infants
- 34-36 6/7 weeks gestation
- Close monitoring for at least first 24 hours
complications of late pre term infants are due to
-Inadequate or delayed transition from intrauterine to extrauterine life
-Up to 20% of NICU admissions
-Morbidity rate doubles for every week below 38 weeks
Late Preterm Infants- respiratory
-Lungs immature
-Decreased surfactant since this is produced at 24 weeks= hard time keeping lung tissue open
-Immature respiratory control
-Decreased muscle tone so cant breathe as well
late preterm infants- thermal control
-Decreased brown fat for thermogenesis (uses this for energy and broken down to help keep warm
-Decreased white fat for insulation
late preterm infants- feeding difficulties
-Immature coordination
-Inadequate milk transfer
-Sleepier
-Low milk supply
late pre term infants- hyperalbuminemia
-Delay in metabolism and excretion
-2X greater risk for significantly high levels
-More susceptible to bilirubin toxicity
late pre term infants- immature brain
-Cortical volume increases 50% in volume between 34-40 weeks, great increase in surface area
-Leads to other problems
-Needs more sleep to conserve energy
late preterm infants- hypoglycemia
-Low glycogen stores
-Immature pathways to make glucose
late pre term infants- risk of sepsis
Immature immune system
late pre term infants- care/prevention/assessment
- Close monitoring for at least 24 hours Q 4 hours : More frequent vital signs
- Assessment/Prevention:
-Hypoglycemia
-Hyperbilirubinemia
-Prevent infections
-Hypothermia - Feeding
-Lactation consultation
-Encourage frequent feedings and assess adequacy - Unlimited skin-to-skin contact: helps improve feeding effectiveness and keep warm
- Car seat challenge prior to discharge: put them in the car seat for how long it takes to get home and want 02 to stay above 90%
Birth Injuries
- Cephalohematoma: Monitor closely for jaundice
- Fractured Clavicle: Fairly common
-Risk factors: Macrosomia, Shoulder dystocia, Forceps and vacuum, Unpredictable - What treatments can be
done to help?
-Pain management
-Immobilization for 7-10 days
-Potentially physical therapy
Neurological Injuries cause
Excessive or improper traction on
head during birth
Brachial plexus injury
-Erb’s palsy-damage to network of nerves for arm, hand and shoulder (C5-8 and T1)
-Klumpke’s- nerves of forearm and hand (C8 and T1)
- assess if moving extremities equally
risk factors for hypoglycemia
-Neonate of diabetic mother
- large birth weight
-SGA
-Preterm
- postdate
- maternal chorioamnionitis
-Hypothermia
-Birth trauma: FORCEPS OR VACCUM
-RDS
-Resuscitation
What assessments and care should occur for all newborns related to hypoglycemia?
-Identify risk factors
-Prevention—early feedings, prevent cold stress
-Assess for signs & symptoms
Hypoglycemia
Blood sugar <40-45
what can be done with hypoglycemia
- provide calories: attempt breastfeeding but if unable give supplementation with donor breast milk or formula
- warm up up with skin to skin with warm blankets
- reassess in one hour
Signs of hypoglycemia
-Jitteriness
-Poor tone
-Lethargy
-Temperature instability
-Apnea
-Irritability
Neonatal Sepsis
- Leading cause of morbidity and mortality
- Risk of mortality-5-15%; may be as high as 50% if untreated
- 15-20% residual neurologic damage in meningitis
transmission of neonatal sepsis
- Vertical
-Transplacentally-TORCH infections
-Ascending- R/T prolonged rupture of membranes
-Delivery exposure-herpes, GBS - Horizontal: not washing hands between babies and contact with ill providers
types of neonatal sepsis
- Early onset- within first 7 days—GBS #1 culprit: Higher incidence with low birth weight
- Late onset- 8 days to 3 months- Staph, pseudomonas, e-coli
neonatal sepsis symptoms
-Respiratory-Apnea, grunting, tachypnea, cyanosis
-Thermoregulation-Temperature instability, hypothermia
-Neurological- Lethargy
-Poor feeding, glucose instability
-Cardiovascular-brady/tachy, hypotension, poor perfusion
What tests might be ordered to evaluate baby with neonatal sepsis
- CBC
-WBCs-high or low
-Neutrophils-low
-Bands (immature WBC)-high - Blood cultures
- Spinal tap. to see if meningitis
- Others: c-reactive protein, urine culture, chest x-ray
What can be done to prevent sepsis?
-Prenatally: screen/treat infections, education
-Intrapartum: GBS, limit # of VE, avoid AROM too early, avoid PTD
-Postnatal: education
-GOOD HAND HYGIENE
Treatment and Nursing care of neonatal sepsis
-Antibiotics- start prior to blood culture results
-Nutrition-may be NPO
-Assessment- symptoms, weight, I&Os, hypoglycemia, electrolyte imbalances
-Respiratory & cardiovascular support
-Support bonding & parental education
apnea
-Periodic breathing vs. apnea: pauses in respiratory > 20 seconds
-May or may not be associated with cyanosis or bradycardia
- Assess for other things:
Hypoglycemia
Infection
Hypoxia
Fluid imbalances
CNS abnormalities
Transient Tachypnea of the Newborn cause
Failure to clear fluid in pulmonary system
risk factors for Transient Tachypnea of the Newborn
-C-section: squeeze of chest isnt as great so more fluid remains in lungs and has to be reabsorbed which takes time
-Maternal diabetes (increase glucose = decreased surfactant produced)
- asthma
-Male infants
-LGA, macrosomia
-Late preterm
**Resembles classic RDS
Transient Tachypnea of the Newborn s/s
-Rapid rate
-Grunting, retractions and having to use accessory muscles to expand lungs, nasal flaring
- Cyanosis
**Resembles classic RDS
Nursing Care of Transient Tachypnea of the Newborn
Oxygen
Prevent cold stress
Provide calories—oral feedings contraindicated
Asphyxia
-Inability to transition to extrauterine circulation
-No lung expansion and respirations –> hypoxemia –> metabolic acidosis & hypercapnia
-Change from aerobic to anaerobic metabolism
risk factors for asphyxia
-Antepartum factors: anything affecting placental perfusion
-Intrapartum factors: prolonged labor, cord issues, assisted delivery, malposition
-Neonatal factors: prematurity, male gender, infant of diabetic mother, SGA/macrosomia
protective mechanisms for asphyxia
-Brain is immature
-Lower resting metabolic rate
-More efficient energy use
-Able to redistribute lactate and hydrogen ions
asphyxia s/s
- Intrapartum
-Non-reassuring FHR in labor (category 3)
-Cord blood gas pH <7 - Neonatal
-No respiratory effort @ 5 min or APGAR score < 5 @ 10 min
-Need for prolonged resuscitation
-Stunned look or lethargic
-Seizures & CNS irritability
-Hypertonic or hypotonic
-Poor feeding
asphyxia tx
-Rapid identification
-Appropriate resuscitation
-Support oxygenation & ventilation: Monitor closely
-Therapeutic hypothermia: For >36 weeks gestation Cool to 33.5-34.5 C, Initiated within 6 hours ( = Decreased mortality and neurodevelopmental disability rates)
-Provide nutrition
Respiratory Distress Syndrome (RDS) cause
- Absence, deficiency or alteration in pulmonary surfactant
- Alveoli of infant’s lungs are lined with surfactant helps with lung expansion
- Lowers surface tension = reduces pressure required to keep alveoli open with inspiration
-Prevents total alveolar collapse on exhalation= maintains alveolar stability
-Decreased surface tension = increased lung compliance
-Helps to establish functional residual capacity of lungs
-Without surfactant = more pressure must be generated for inspiration = can tire or exhaust preterm or sick infants - Begins to develop around 24-28 weeks and by 35 weeks most babies have enough naturally occurring surfactant to keep the alveoli from collapsing
RDS- antenatal corticosteroids
- IM injection that is repeated in 24 hours
- Joint Commission Perinatal core measure
-Given to women in preterm labor—see slide notes page
-Promote fetal lung development and surfactant production
Recommended to give Corticosteroids if the woman is expected to deliver within the next 7 days:
-24 0/7-33 6/7 weeks
-34 0/7-36 6/7 weeks for women who have not previously received corticosteroids
-23 0/7-23 6/7 weeks based on parents desires for resuscitation
-A single repeat series can be given if < 34 weeks
RDS management
-Preterm birth prevention
-Maintain neutral thermal environment
-Respiratory support & oxygenation: Pulse Ox @ 90% (higher is toxic to sensitive eyes)
-Nutrition via IV
-Maintain BP
-Surfactant administration
1. Prophylaxis- within 15 minutes of birth
2. Rescue treatment- within 8 hours of birth
3. Administered via ET tube
4. Benefits- reduces risk of RDS, pneumothorax, IVH (intraventricular hemorrhage) , bronchopulmonary dysplasia, pulmonary interstitial emphysema
RDS signs
Progressive respiratory difficulty
Grunting, tachypnea, nasal flaring, retractions
Lethargy
Hypotonia
Cyanosis
Hypoxemia and acidosis
CXR-reticulograndular pattern
Increased O2 requirements
Neonatal Substance Abuse Exposure
- With use of illicit drugs, alcohol & tobacco increased risks for:
-Poor or no prenatal care
-Poor weight gain
-STIs
-OB complications - Effects dependent on substance
Neonatal Abstinence Syndrome
- Factors affecting symptoms: Last exposure, half-life, type
- Timing of symptoms
1. Alcohol-3-12 hours
2. Narcotics-2-3 days
3. Barbiturates-1-14 days
Neonatal Substance Abuse Exposure- alcohol
-Fetal alcohol syndrome (FAS)- physical, cognitive and behavioral abnormalities:
1. Facial- small eyes, thin upper lip, short nose
2. Heart, joint, limb, finger deformities
3. IUGR and poor growth after birth
4. Cognitive impairment—COMPLETELY PREVENTABLE!!!
5. Vision and hearing problems, behavior problems
-Alcohol related birth defects (ARBD)
1. Congenital anomalies-heart, skeleton, kidneys, eyes, ears
-Alcohol related neurodevelopmental disorder (ARND)
1. Small head size, brain abnormalities, neuro, cognitive, behavioral problems
Nursing Care of Neonate with Neonatal Substance Abuse Exposure
- Review records
-Assess for withdrawal and anomalies - Obtain toxicology –meconium and urine screening, cord tissue sampling
- Control environment
-Dim, quiet, group care activities - Nutrition
-Poor feeders
-Small, frequent feedings
-Higher calorie formula? - Promote self-soothing/regulation
-Swaddling, gentle rocking, non-nutritive sucking - Promote bonding
- refer to social work
DESCRIBE the nurse’s initial response to PPH findings and include the rationale for the action/s you described.
Most common cause of excessive blood loss at this time is most likely uterine atony, especially because Andrea exhibits several risk factors
Priority action: Assess fundus and perform fundal massage; helps the uterus contract
Call for help; code white as needed (if continues to hemorrhage or decline in vital signs)
Check bladder and perineum; empty bladder as necessary; full bladder can cause uterine atony leading to a postpartum hemorrhage
Give hemorrhage medications
c. DESCRIBE the measures that the nurse should use to care for Andrea’s physiologic needs and to support her and her family and attempt to reduce their anxiety during a PPH
Explain situation and all care being provided
Provide comfort and support measures—remember hemorrhage medications can cause painful uterine cramping—provide analgesics, prn
Allow for opportunities to interact with newborn as able—encourage breastfeeding once stable as that will help uterus to continue to contract
Allow an opportunity for Andrea and her family to verbalize their feelings related to this complication as it can be traumatic
a. Factors that can increase a postpartum woman’s risk for puerperal infection
Consider antepartum factors—hx of DVT, UTI, mastitis, pneumonia; DM, alcoholism, drug abuse, malnutrition, immunosuppression, anemia, GBS
Consider intrapartum factors—c-section/vacuum/forceps birth, prolonged rupture of membranes, intraamniotic infection, prolonged labor, internal fetal/intrauterine monitors, multiple SVEs, epidurals, retained placental fragments/manual removal, postpartum hemorrhage, hematomas, lacerations/epis
b. Infection prevention measures that nurses should be using when caring for postpartum women.
Emphasize measures to maintain resistance to infection (nutrition, rest, hygiene)
Standard precautions—handwashing, proper use of gloves, care of equipment, vaccines (Flu, COVID), avoiding working while ill
Teach woman about preventing infection—safer sex practices, hygiene, avoiding family members who are ill
c. Critical nursing measures that are essential in care management related to the prevention and early detection of puerperal infection.
- Identify risk factors for infection
- Limit vaginal exams, invasive monitoring/procedures during labor if possible
- Recognize deviations in normal that could be s/s of infection:
- Endometritis—most common postpartum infection
–Fever, increased pulse, chills, anorexia, nausea, fatigue, lethargy, uterine/fundal tenderness (significant discomfort), foul-smelling lochia, elevated WBCs
–Treatment—Broad-spectrum IV antibiotics; rest, nutrition, pain relief - Wound Infections—C-section or repaired lacerations/episiotomy—usually develop after discharge from the hospital
–Fever, erythema, edema, warmth, tenderness, pain, seropurulent drainage, wound separation.
–Treatment—IV antibiotics, incision and drainage
–Nursing care—frequent assessments, V.S., wound, comfort/pain relief; patient education on hygiene, self-care, and s/s of worsening condition - UTIs
–Dysuria, frequency, urgency, low-grade temperature, urinary retention, Costovertebral angle tenderness or flank pain.
–Treatment—antibiotics, hydration, analgesia
–Nursing care—patient education on proper pericare, etc.
risk factors for DT
Venous stasis and hypercoagulability of pregnancy continuing into the postpartum period until 6 weeks
Cesarean birth
Obesity
Age over 35 years
Multiparity
Smoking
signs of DVT
Unilateral leg pain, tenderness, warm, red, swollen calf
Positive Homan’s sign—not very specific; other diagnostic tests will be used (i.e. ultrasound)
warfarin teaching
Warfarin is an oral form of anticoagulant
This medication poses little risks to the breastfed infant; very low Warfarin levels are present in breastmilk; No special precautions are needed
How to assess leg and for signs of unusual bleeding
Proper use of elastic/support stockings—need full length not knee high
How to take anticoagulant safely and importance of follow-up
Practices to prevent bleeding while taking an anticoagulant (i.e. soft bristle tooth brush, electric razor, care while using knives, etc.)
Diet considerations—maintain a consistent diet of vitamin K foods—don’t have to be limit or avoid completely, just consistent
Avoidance of pregnancy because Warfarin is teratogenic—avoid any contraception containing estrogen as this increases risk of clots
Activities: discuss avoiding activities that have a risk of falls or injuries due to the risk of bleeding while on Warfarin (i.e., avoid skiing due to falls/collisions with other skiers causing a head injury)
