midterm Flashcards
- Definitions
Gravida: woman who is pregnant
Gravidity: pregnancy
Multigravida: woman who has had two or more pregnancies
Multipara: woman who has completed two or more pregnancies to 20+ weeks gestation
Nulligravida: woman who has never been pregnant
Nullipara: woman who has not completed a pregnancy with beyond 20 weeks gestation
Preterm: pregnancy between 20-0 and 36-6
Primigravida: woman who is pregnant for the first time
Primipara: woman who has completed one pregnancy with fetus or fetuses who have reached 20 weeks of gestation
Term: pregnancy from 37-0 to 41-6
Viability – capacity to live outside the uterus (22 – 25 weeks gestation)
Postpartum period:
interval between birth and return of reproductive organs to their nonpregnant state
lasts 6 wks
- Postpartum Maternal Assessment – key points
- Maternal Assessment
- Postpartum teaching
- Breastfeeding (Benefits, LATCH tool for assessment of feeding)
- Uterus
-Fundal height and lochia are indicators of progression of uterine involution.
-Involution Process: return of uterus to true pelvis after birth
-Progresses rapidly
-Fundus descends 1 to 2 cm every 24 hours
-2 weeks after childbirth uterus lies in true pelvis
-Sub involution: failure of uterus to return to non-pregnant state
Common causes are retained placental fragments and infection
-Contractions compress blood vessels to stop bleeding
-Hormone oxytocin, released from pituitary gland,
strengthens and coordinates uterine contractions
-Placental site (vascular constriction & thrombosis reduce the placental site)
- Lochia: 3 types
lochia is Post birth uterine discharge
- Lochia rubra
-bright red flow
-made of blood and decidual debris (mucosal lining of uterus)
-lasts 3-4 days - Lochia serosa
-old blood, debris, leuks, serum
-colour: pink/brown
-mediation duration 22-27 days (12 days on google)
3.lochia alba
-leuks, epi cells, serum, mucus, bacteria
-duration 4-8 wks. (12 days - 6 wks on google)
- cervix
-soft immediately after birth
-2-3 cm 2-3 days pp
-by 1 wk, 1 cm
-ectocervix (portion that protrudes into the vag) appears bruised and has small lacerations ***infection risk
- vagina, perineum
-gradually decreases in size
-regains tone (never completely)
-estrogen deprivation- thins mucosa and absence of rugae
-thickening of mucosa returns with ovarian cycle
-episiotomies heal ~2wks
-hemorrhoids common, decrease ~6 wks
-pelvic muscular support
-kegels, ~6 months, supportive tissues were stretched/torn during birth
- breasts
The return of ovulation and menses is determined in part by whether or not the woman is lactating (breastfeeding).
BF mom
-colostrum
-tender for 48 hrs after start of lactation
non BF mom
-engorgement resolves in 24-36 hrs after milk comes in
-lactation ceases within days-1wk
-breast binder/tight bra/ice/cabbage leaves/mild analgesics
3 CVS
blood volume
-vag loses up to 500 ml
-c/s 500-1000 ml
-blood vol decreases within a few days dt diuresis
CO
-remains elevated for 48 hrs after birth
-VS- HR,BP return to normal after 2-3 days
Blood components
-hemoglobin and hematocrit - moderate drop for 2-4 days, then normal by 8 wks
-WBC - normal by 10-12 days
-coagulation factors - elevated with risk of thromboembolism!!!
Varicosities
-return to prepreg state
- Resp system
-immediate decrease in intra-abd pressure = increase in chest wall compliance, reduce pressure on diaphragm
-reduced pul blood flow
-rib cage elasticity returns in months
-loss of placenta = drop in progesterone = paCO2 rises
-BMR returns to normal 1-2 wks pp
- Endocrine system
placental hormones
-loss of placenta= drop in estro and progest
-decrease in hCS, cortisol, and placenta; enzyme insulinase = reverse effects of DM = low blood sugar levels
-mom w/ T1DM require less insulin for a few days pp
-mom w/ GDM go back to normal within days pp
-hCG (human chorionic gondatropin) disappears quickly from maternal circ. (detectable 3-4 wks pp)
Pituitary hormones and Ovarian function:
-prolactin levels highest during 1st month BFing and remain high during BFing
-influenced by BFing, duration of feeds, strength of suck
-BF mom - ovulation return 70-75 days
-non BF mom - ovulation return 27 days
*may ovulate before first menstrual cycle
- urinary system pp
urine components
-renal glycosuria disappears 1 wk pp
-proteinuria resolves by 6 wks pp
-ketonuria may persist after dehydration
-lactosuria may occur in lactating moms
-bUN increases with autolysis of the involuting uterus
fluid loss
-diuresis of extracellular fluid
occurs at night for 2-3 nights
urethra and bladder
-excessive bleeding can occur dt displacement of uterus if bladder is distended
-stress incontinence
- GI system pp
appetite
-very hungry after recovery from analgesia, anesthesia, and fatigue
bowel
-normal to not have BM for 2-3 days pp
dt decreased muscle tone, lack of food, discomfort dt episiotomy, hemorrhoids, lacerations
-forceps/vacuum/anal sphincter laceration - increase risk of incontinence, flatus. resolves in 6 months
-C/S - abd pain from buildup of flatus
-encourage mom to move
- integumentary system pp
-melasma “mask of preg” disappears
-hyperpig of areolae and linea nigra may not disappear
-striae gravidrum - wont disappear
-hair loss 3 months pp
-fingernails return to prepreg strength and consistency
- Musculoskeletal system pp
-joints stable 6-8 wks pp
-6. wks for abd wall to return to prepreg
-diastasis recti abdominis - walls separate
-ongoing hypermotility of joints
-change in center of gravity
-permanent increase in shoe size
- Neurological system pp
-headache common for 1 wk pp dt fluid balance
-pp headaches may be dt pre=eclampsia, stress, leakage of cerebrospinal fluid into the extradural space during the placement of the needle for epidural/spinal anaesthesia
**careful assessment
- immune system pp
mildly suppressed during preg, returns gradually
rebound can trigger flare ups of autoimmune conditions (eg multiple sclerosis)
When to do a PP assessment
SVD
-q15min since delivery for 1 hr
-at 2 hrs pp
-then 1x per shift
-increase using nursing judgment
C/S
-q15min since delivery for 1 hr
-2 hrs
-q4h for first 24 hrs
-then 1x per shift (8-12)
-increase using nursing judgment
Head to Toe
VS
sedation scale
BUBBLE LEP
skin to skin/ bonding and attachment
support, family function, family planning
concerns, past hx
Breasts
Uterus
Bladder
Bowel
Lochia
Episiotomy/perineum
Legs and feet
Emotional coping/mental health
Pain
discharge 12-36 hours after SVD if no complications
normal VS
T 36.7-37.9
HR 55-100 bpm
RR 12-24 unlabored
SBP 90-140
DBP 50-90
sedation scale
1 awake oriented
2 drowsy
3 eyes closed but reusable to command
4 eyes closed but reusable to mild physical stim
5 eyes closed but UNrousable to physical stim
PP Assessment: Breasts, BF
normally soft, filling with milk day 3-5
intact skin
not sore
produces small amount of colostrum
hand expression
c shape
press back toward chest
compress (squeeze) while rolling thumb and fingers forward
relax
rotate hand to all section of breast
uterus assessment
firm. midline. at or below umbilicus
void first
supine. knees flexed
support uterus above pubis symphysis (not for c/s)
no s&s infection
incision healing, dressing dry and intact
dressing can come off after 24 hrs
Bladder assessment
void comfortably and completely 2-3x/shift
diuresis and diaphoresis
catheter 30 ml/hr post c/s
peribottle
hydration
episiotomy/tears preventing mom
Bowel assessment
may or may not have BM
3x/day or 1x/3days
offer stool softeners
post c/s normal findings:
bowel sounds present
minimal abd distension
flatus passed
may eat/drink when hungry/thirsty
Lochia assessment
amount. colour. clots. odour. stage of involution
scant <2.5cm
light <10cm
moderate >10cm
heavy one pad saturated within 2 hours
rubra- bright red. 1-3 days pp
serosa - pink/brown 3-10 days pp
alba - yellow/white 10 days-6 wks pp
loonie sized clots normal as long as can break apart
no saturation of pad in one hour
trickling when ambulating
no foul smell
overall 4-8 wks lessens
Episiotomy/perineum
Legs/feet
pain <4/10
well approximated
no swelling, bruising, hematoma, discharge
no infection
analgesics, teabags, stool softeners
edema
pedal pulses present
no DVT signs
emotional coping and mental status
response to birth
PPD
support
sleep
PPH
VS out of range -> boggy uterus -> lots of lochia -> pain
action:
-retake VS, sedation
-massage and observe flow
-compare against prev. pain assessment
What should you do if you have a pt in PPH?
1. notify the obstetric hemorrhage team
2. maintain circulation
3. identify cause
4. treat cause
NURSING INTERVENTIONS FOR POSTPARTUM HEMORRHAGE (quizlet)
Check fundus for firmness, bleeding color, & amount
VS
Maintain venous access
Assess bladder distention
Give oxygen
Call primary healthcare provider
Draw labs = PT, pTT, HCT, HGB
skin to skin assessment
for bonding and attachment
parents interact and respond to feeding cues
cuddling, eye contact, talking
effective consoling techniques
respond to infant in loving sensitive manner and is emotionally and physically available
support and family assessment
support system
family function
safe home environment
healthy lifestyle (no smoke, drug, alcohol)
healthy eating and fluid intake
activity and rest and ambulation
concerns and past hx
communicable diseases
-HIV, STI
RH, blood group
-RH incompatibility when mother rh neg and infant rh pos
GDM
HTN
Birth history
GTPAL
Baseline VS
discharge criteria
pp pathway - must be all N (normal) or plan in place for V (variances)
must have all discharge education complete
GTPAL
Gravida
Term (37-0 + wks)
Preterm (20-0 - 36-6 wks)
Abortion <20 wks
Living
post term is beyond 42 wks
signs of adequate milk transfer
-onset of copious production by day 3-4 post birth
-firm tugging on nipple but no pain
-uterine contractions and increased vaginal bleeding while feeding (1st week)
-increased thirst
-breasts soften/lighten
milk ejection (let down) warm rush, leaking
-baby feeds 8-12x/24 hrs
-latches without diff
-bursts of 15-20 sucks
-audible swallowing
-sleepy and relaxed appearance
-starts feed eager, appears content after
-at least 3 substantive BM
-6-8 wet diapers q24h after day 4 pp
how often to BF
-exclusive BF 6 months
-continue BF for 1 year, after that your choice
-start giving foods at 6 months
non-nutritive benefits of BFing
for mom:
-faster completion of uterine involution and lochia flow (=saving iron stores=higher hemoglobin= more energy to do stuff)
-enhanced metabolism
-bonding
-decreased risk of
breast cancer
ovarian cancer
HTN
CVD
hypercholesterolemia
post-menopausal osteoporosis, RA
-natural contraceptive. hormone level is high enough to suppress ovulation (lactational amenorrhea)
-contains stem cells
for baby:
-contain oligosaccharides which feed the gut microbiome
-bonding
-immune system, reduced risk of common childhood diseases
-bifidus factor, interferon, resistance factor, lipase, anti-inflam agents
-higher intelligence
exclusively BF children have 10 IQ points higher than non-BF
-decrease risk of SIDS for BFing at least 2 months, doesn’t need to be exclusive. Duration of BFing decreases risk
overall: BFing decreases healthcare costs
hazard of ABM
can be harmful if not produced, prepared, given according to directions
colostrum
-establishes colonization of newborn gut microbiome. to develop immune system
-fat soluble vitamins
-protein
fetal hemoglobin needs to breakdown and bind to bilirubin protein to be excreted
-less fat (fat is hard to digest)
-lactoferrin
acts as a transport for iron from the gut to the body.
-laxative effect to bring about massive BM to clear the gut and excrete bilirubin from the breakdown of fetal hemoglobin
-aids in rapid gut closure of their gut - helps with resistance against organisms
normal volume intake
first 24 hrs - 2-10 ml.
happens within first 2 hours of birth
then crash recovery sleep for 6-8 hrs
then feed q2-3 hrs
24-48 hrs - 5-15 ml
48-72 hrs - 15- 30 ml
72-96 hrs - 30- 60 ml
how much milk is produced
colostrum:
first 24 hrs - 37 ml. (7 - 123 ml range)
Breast milk:
day 5 - 500 ml/24hrs
3-5 months - 750 ml/24 hrs
breast milk production
-first stimulated by hormones, then by adequate milk removal
-early and often removal increases milk supply
-need good quality latch to stimulate receptors deep in the areolar
-nerve impulses from sucking -> prolactin released -> prolactin induces breasts to secrete milk
skin to skin benefits
-temp regulation
-decrease stress and cortisol in baby
-establish flora
-promote BFing
-triggers ventral feeding reflex
LATCH assessment tool
L - latch
-mouth to nipple
-nose to nipple
-mouth as wide as a yawn
A - audible swallowing
-normal for bursts of sucking before swallowing
-frequency of swallowing increases
-allow rest periods to massage breasts to bring down more milk
T - type of nipple
-everted - spontaneously
-flat
-inverted
-no introduction of nipple shield in 1st 24 hrs
C - comfort
-good latch should not be painful
-if trauma from poor latching, apply EBM to nipple
H - hold
-use pillows to release tense pectoral muscles
-baby at breast level
-cup breast with C or U
-positions include football, laid back, sidelying
feeding cues
early - stirring, mouth opening, seeking/rooting
mid - stretching, increasing physical movement, hand to mouth
late - crying, red, agitated movements
-cuddle, skin to skin, talking, stroking
