Maternity Flashcards
Gravida
A person that is pregnant
Gravidity
A pregnancy
Multigravida
A person who has had 2 or more pregnancies
Multipara (multip)
A person that completed 2 or more pregnancies to 20+ weeks gestation
Parity
Number of pregnancies in which fetus(es) have reached 20 week gestation.
Not affected if fetus is alive or stillborn.
Primigravida
A person who is pregnant for the first time
Primipara (primip)
A person who has completed one pregnancy in which the fetus(es) have reached 20 weeks gestation
Viability
Capacity to live outside the uterus. Typically 22 to 25 weeks gestation.
Term
A pregnancy from the beginning of 37 weeks to 40 weeks and 6 days
Preterm
From 20 weeks to 36 weeks and 6 days
Early term
A pregnancy between 37 and 38 weeks and 6 days
Full term
A pregnancy from 39 weeks to 40 weeks and 6 days
Late term
41st week of pregnancy
Post term
Pregnancy after 42 weeks
Abortion
Can be spontaneous or therapeutic.
Loss of pregnancy typically before 20 weeks.
Living
Number of living children
Puerperium
6 week period after childbirth in which mothers reporductive organs return to pre-pregnancy state (as close as it will get)
What are the 6 periods of Perinatal Continuum of Care?
1. Preconception ANTEPARTUM 2. 1st trimester: conception to 12 weeks 3. 2nd trimester: 13 weeks to 26 weeks 4. 3rd trimester: 27 weeks to delivery 5. Intrapartum: labour and birth 6. Postpartum (or 4th trimester): 6 to 8 week period that begins an hour following the birth of the fetus and expulsion of the placenta. (High risk time for health changes)
What care should a person have during the preconception period of the Perinatal Continuum of Care?
Before a person gets pregnant, ideally they would have a healthy lifestyle, and mindset before hand
And be immunized
What is the typical length of stay (LOS) for vaginal and C Section?
Vaginal- 24 hrs
CS- 48 hrs
As long as clients meet criteria.
Factors that influence psychosocial postpartum adaptations?
- pregnancy and birth experiences (some need to share story, empathetic listen)
- physical recovery
- role attainment
- bonding and attachment behaviours
- newborn and infant characteristics
- fatigue: implication for postpartum depression
- ability to meet needs
- emotional responses
- socioeconomics
- family dynamics
- social support
- cultural considerations
These can preexist and intensify during pregnancy. Difficult for attention to shift from pregnant person to baby for some.
How does a nurse assess bonding and attachment behaviours?
Assessed (and charted) by watching interactions
- making eye contact
- holding baby
- responding when baby cries
- they way they speak about their baby
- calling baby by name if they have one
Phases of Maternal Postpartum Adjustment
Rubin,1961
- TAKING IN (DEPENDENT) first 24 hrs
- Focus: self and meeting your own basic needs
- Exited and talkative, shows wonderment
- Desire to review birth experience
- Reliance on others to meet needs (comfort, closeness, rest, nourishment)
- May seem passive and not taking active role - TAKING HOLD (DEPENDENT-INTERDEPENDENT) lasts 10 days to several weeks
- Focus: care of the baby and competent mothering
- Desire to take charge, may still not feel confident
- Readiness to learn. Optimal time for teaching
- Handling of physical discomforts, emotional changes
- Nurturing and acceptance by other is still important
- Postpartum blues possible
- Partner may feel ignored due to maternal preoccupation with baby - LETTING GO (INTERDEPENDENT)
- Focus: forward movement of the family as a unit
- Reassertion of relationship with partner
- Reassumption of sexual activity
- Resolution of individual roles.
Stages of becoming a mother
Mercer, 2004
- Committment, attachment to unborn baby. Preparation for birth and motherhood during pregnancy
- Acquaintance/attachment of the infant. Learning to care for the infant. And physical restoration during the first 2 to 6 weeks following birth
- Moving towards a new normal
- Achievement of a maternal identify through redefining self to incorporate motherhood (around 4 months)
When does parental development or role attainment start?
Pregnancy. Accepting you are pregnant is the first step.
Cultural considerations and influences in maternity?
Beliefs and values differ. Cultures often more visible during ‘rights of passage’
- health, self care and newborn care practices
- interaction with healthcare providers
- family dynamics
- newborn and infant feeding practices
- lying in periods to take care of self, while others care for baby
Ask your client what pregnancy, birthing and feeding practices mean to them and provide client centered care.
Parental development tasks for fathers
- New expectations and priorities
- Strike a balance between work, own needs, partners and baby’s needs
- redefining role
- reaping rewards: often when baby can interact with dad
Parental development tasks: LGBTQ+
Similar challenges to mother and father
- become attached during pregnancy to baby
- new priorities and new normal
- striking a balance with work, partner, self and baby
- redefining role as parent
Added challenges:
- lack of family acceptance
- public or provider ignorance
- parental care is heteronormative, which results in unfavourable health care outcomes. People need to feel safe when accessing health care.
Learning needs:
Common needs vs individualized needs
Nursing teaching priorities can differ from clients learning priorities. So find out what’s important to them to know before going home. Assess readiness to learn.
Common needs: often discharge classes.
- information
- shared experiences
- car safety, sleep safety
- psychological support
- social and community support
Individualized needs:
- things important to your client. Nurse at bedside can provide.
Community resources examples
Assess a client’s need for social support. Needs change overtime.
Community health centres
Online resources
Healthy baby healthy child (screening tool)
Describe ways a nurse may facilitate transition home for client?
- Provide common need and individualized need information
- Support mom physically and psychologically
- Advocate for mom and baby apart and together
- Community program awareness
- Pay attention to baby and mom’s needs
- Assess, monitor and support adaptations: physical, social and emotional.
- Provide non judgmental, inclusive care to all parents.
Where does childbearing, healthcare and teaching predominantly take place?
In the community.
Postpartum Assessment
BUBBLL-EE
breasts Uterine fundus Bowels Bladder Lochia Legs Episiotomy/laceration/incision Emotional status ... And vital signs!!
How does breastfeeding decrease risk of PPH
Breastfeeding immediately after birth and early postpartum stimulates release of oxytocin which decreases blood loss and risk of PPH
How do you assess breasts
- inspect for size, shape, symmetry
- palpate for degree of fullness (soft, filling, full, engorged), tenderness, lumps (blocked milk duct), pain
- inspect nipples for shape (erect, flat, inverted), redness, bruising, blisters, discomfort, fissures
How to assess uterine fundus?
- Palpate for consistency: boggy or firm
- palpate for location: midline/deviated to left or right
- palpate for heigh of fundal involution: in relation to umbilicus (1/U, @U or U/U, U/1)
How do you assess bladder?
- Assess amount voided, fullness after void, burning and pain while voiding
- Assess for distension (or fundus deviated): sign of bladder full
Assess bowels
Assess for last BM - common to not occur for 2 to 3 days
- if no BM, assess for abdominal discomfort and distention
- Auscultate for bowel sounds in all 4 quadrants.
How to assess lochia?
Assess colour (rubra, serosa, alba) Assess amount (scant, small, moderate, heavy) Foul odour?
How to assess legs?
Peripheral edema Venous thromboembolism (red, tender, unilateral leg pain, localized edema)
How to assess episiotomy/laceration/incision
Visually assess perineum for edema
Assess REEDA: Redness, edema, ecchymosis, discharge/discomfort, approximation.
Assess for hemorrhoids (number, size, discomfort)
How to assess emotional status
Assess coping
Assess bonding/attachment behaviours.
Puerperal phase of role attainment.
Normal vital adult ranges and expected changes in postpartum
BP, HR, RR, T
BP: 120/80.
Tends to run lower in women so check pregnancy baseline to compare. Influenced by blood loss, epidural and orthostatic hypotension
HR: 60-100 BPM
10-15 BPM increase over pregnancy baseline can be normal due to demands of labour, physical shifting of diaphragm and rotation of heart.
RR: 12 to 20 breaths/minute
May take shallow breaths more rapidly (increase to 16 to 24) but quickly returns in postpartum
T: 36.5 TO 37.5 (axillary)
Epidurals can cause a higher temp, but should come down quickly. Dehydration can cause higher temp. Watch for infection.
What is the function of the placenta?
Delivers oxygen and nutrients to fetus, removes waste and O2 from fetuses blood
Anchors fetus to uterus.
Why does the uterus have to contract to stop bleeding after placenta detaches?
The uterus consists of layers of muscle fibers with veins weaved within layers. It does not have coagulation factors like the rest of the body. So the uterus has to squeeze (contract) to restrict the blood flow.
What is the effect of oxytocin in the body post birth?
It is released by the posterior pituitary gland naturally during orgasms and birth. It contracts smooth muscle in the ducts of the breast to let milk down, and contracts the uterus which decreases PPH
How is the risk of PPH minimized?
Exogenous oxytocin is routinely administered after 2nd or 3rd stage of birth to stimulate uterine contraction.
We palpate and massage fundus to confirm its contracted or stimulate it to contract.
Having babies breastfeed immediately reduces PPH due to triggering endogenous oxytocin release
What happens to uterine contractions during first 1 to 2 hrs?
Can decrease in intensity and become uncoordinated. Why it’s important to give exogenous oxytocin.
Afterpains
Uterine contracting while returning to pre-pregnancy state brought on by oxytocin.
Who is more likely to experience after pains?
Multips experience more often than primips because it’s more difficult to fully contract
Breastfeeding and exogenous oxytocin increase after pains
Uterine involution
What is it and what is the rate?
Multip vs primip?
The process of the uterus returning to as close to pre-pregnancy state. Begins as soon as the placenta is born. Shrinks from abdominal organ to pelvic organ.
RATE: initial rise in first 12 hours, then involutes 1 to 2 cm q24hrs.
First 12 hours= just above umbilicus. Pelvic organ by 9 days to 2 weeks.
Increased under oxytocin influence.
Multip vs primip: think of uterus as elastic band. Every time it’s stretched, it involutes to a little bigger than last time.
24 hrs post birth, where do you expect the fundus?
About the same place as 20 weeks pregnancy. About 1/U
What is Subinvolution? Why may it occur?
Not involuting the way it should be. Could be due to placental fragments left behind or infection, preventing the uterus from contracting.
Often present with fever and other signs.
How do you Palpate the uterus fundus?
Two hand technique:
- stand on side of bed with pt supine. Use non dominate hand to anchor uterus at symphysis pubis and support lower segment of uterus, as you apply pressure with the dominant hand at the top of fundus.
- start high and palpate down. Feels like a round hard ball if firm
- as you assess, note how much blood is coming out of vagina. As you squeeze it may gush, which does not indicate a PPH unless it doesn’t stop.
- assess for height, consistency, and location.
During a fundal assessment, if you do not anchor the uterus, what are you risking?
Uterine inversion
What can a full bladder do to the uterus postpartum?
Make the uterus boggy and deviated to side
Describe the 3 types of lochia:
- Rubra (red): lasts 3 to 4 days and is heavy
- blood, small clots, tissue debris - Serosa (pink-brown): 22 to 27 days (some women 10 days)
- old blood, serum, leukocytes, tissue debris - Alba (yellow-white): 2 to 6 weeks (can be 4-8)
- serum, leukocytes, mucus, epithelial cells
How would you describe lochia after 2 hours of bleeding (on pad)?
Scant: 5 cm
Small: 10 cm
Moderate: 15 cm
Heavy: >15 cm
PPH vs blood gushing from breastfeeding?
Breastfeeding can cause gushes because of oxytocin. Lochia would gush, trickle, then stop. PPH would continue heavily bleeding
Clots vs placental clots
Clots are normal within the first few hours after birth, placental clots are concerning and are reportable to avoid infection or PPH
Clots are described in terms of size (in relation to coins or fruit). Anything bigger than a plumb is likely placental fragments.
How to tell the difference: pull apart or break with fingers. A placental clots cannot break.
How to determine if heavy bleeding is lochia vs non lochia blood flow?
If the uterus is firm, yet blood is consistently gushing from vagina, it is likely a laceration at the cervix or vaginal wall that was missed or cannot be seen visually.
Report to dr or midwife.
Laceration degrees
Tissue that spontaneously rips
1st degree: most superficial. Sometimes requires stitches, sometimes doesn’t
2nd degree: goes through perineal muscle
3rd degree: continues through perineal muscle and anal sphincter
4th degree: tears through pernieal muscle, anal sphincter and rectum.
3rd to 4th risks takes weeks to recover. Includes laxitivr and plenty of fluids. Greater risk for genital and urinary issues in current and older adult life.
Episiotomy
Midline vs mediolateral?
No longer standard practice. It is done to avoid laceration
happens at time of crowning or when forceps need to be used during 2nd stage of labour.
Midline runs the risk of extending into the anus, causing a 3rd to 4th degree laceration.
Mediolateral line is used to avoid further tearing.
Therapies for perineum pain
Ice therapy: first 24 hrs helps reduce swelling and provides relief (20 mins on, 20 mins off)
Peri bottle: teach to clean and dry self by patting with towel. Can dilute urine while voiding if stinging
Sitz bath: after 24 hrs, placed on toilet and client can sit in it. Warm water.
How does a maternal assessment differ for a client who had a C/S?
vital signs
BREAST- same
UTERUS FUNDUS- becareful of incision. Do while they are still numb or pain meds are in peak effect.
BLADDER: foley catheter usually in for 12 hrs post
BOWELS: more abdominal pain, encourage them to move around as soon as they can. Absent of bowel sounds can be post-op complication
LOCHIA: often slightly less, surgeon sometimes wipes uterus
LEGS: increased risk of venous clot, encourage movement
INCISION/PERNIEUM: assess sutures when dressing comes off. Assess pernieum as sometimes clients push before C/S
EMOTIONAL STATUS: Can be difficult if C/S wasn’t planned
What is the diet restrictions for C/S and vaginal birth?
Vaginal: can tolerate regular diet
C/S: also surgical patient so special considerations.
Ice chips to clear fluid to solid foods. Only once peristalsis returns to prevent bowel obstruction if there is a post op complication.
Identify 3 types of postpartum complications
- Infection
- Postpartum hemorrhage
- Perinatal mood disorders
What is postpartum hemorrhage (PPH)?
Blood loss causing hemodynamic instability. Any amount that causes the client to have symptoms (weak, dizzy)
Life threatening with little warning.
PPH Risks- 4 T’s
- Tone: uterine tone, anything that reduces tone is a risk factor
- Tissue: retained placenta fragments
- Trauma: trauma to placenta (placenta fragments separating prematurely)
- cloTting: pre existing issues or develops clotting issue bc of labour complication.
Early vs late PPH
Early PPH: Most commonly caused by uterine atony being boggy
Later PPH: up to 6 weeks postpartum until uterus is completely involuted. Usually caused by infection of placental fragments
What would you do if you were alone with a patient during a PPH
stay with patient, use call bells and begin fundal massage. If you have oxytocin, administer.
What are 3 types of perinatal mood disorders (PMD)
- Postpartum blues
- Postpartum depression (no psychosis)
- Postpartum depression (psychosis)
Postpartum blues
50 to 80%
Duration: peaks day 5, decreases by day 10
Symptoms: labile emotion, fatigue, sadness, anger, insomnia
No functional impairment.
Intervention: reassurance. Most clients will experience blues, give anticipatory guidance. These feelings are normal and expected. Assess support and community resources.
Postpartum depression (no psychosis)
10 to 15 %
Duration: weeks to 1 year
Insomnia/hypersomnia, fatigue, appetite change, worthlessness, guilt, irritability, inability to cope, crying, intense irrational fears.
Treatment: counselling, meds, peer support, CBT, psychotherapy
Postpartum depression (psychosis)
1-2 in 1000 births
Duration: 2 to 8 weeks. Usually a preexisting condition
Depression, delusion, thoughts of harm to self or baby, overactive, disorganized behaviour. Inability to care for infant
Treatment: mental health emergency, hospitalization. Baby can be slowly reintroduced under supervision once client is stable.
Postpartum depression risk
Strong
Moderate
Weak
STRONG
Prenatal depression or anxiety
Personal or family history of depression.
MODERATE
stressful life events
Lack of social support
Partner violence
LOW single parent Stress of child care Low socioeconomic status Unwanted or unplanned pregnancy
What is postpartum infection? (Puerperal infection)
Common Types?
An infection of the genital tract that occurs within 28 days after miscarriage, induced abortion, or birth.
Endometriosis
Wound infection
UTI
Mastitis
Endometriosis?
Infection of lining of the uterus. Incidents higher after C/S.
signs- fever, increased pulse, pelvic pain, uterine tenderness, foul smelling, profuse lochia
Wound infection
C/S incision or repaired laceration or episiotomy.
More common after C/S (given prophylaxis antibiotics)
Urinary tract infection (UTI)
Increased risk factors are catheterization, epidural, frequent pelvic exams, history of UTI.
Mastitis
Breast infection. Obstructs milk flow Almost always unilateral and develops well after milk has been established. If not treated can lead to breast abscess.
Localized pain, edema, redness
Infected mastitis: S. Aureus enters through nipple fissure
Non infected mastitis: blocked duct that wasn’t addressed.
Breast milk composition
Very diff for each baby depending on needs and development. Preterm would be diff than term. Changes over time to meet babies needs.
Immune factors Growth factors Protein (70% whey, 30% casein) Digestive enzymes Fats: change from feed to feed Carbohydrates Vitamins (A,B,C,D,E,K) Mineral (calcium, sodium, chlorine, copper, zinc, iron, selenium, iodine, fluoride) 87% water
Benefits of breastfeeding for infant
Easily digested and absorbed Laxative effect Transfer of antibodies and immune factors Maturation of GI tract Neurodevelopment advantage Analgesic effect Better facial, oral, speech development