Module 3A Flashcards
Puerperium
Begins after delivery of placenta and last approx 6 weeks.
“4th trimester”
Involution
Retrogressive changes that return uterus (organ) to nonpregnant size and condition
What are the 3 retrogressive processes for uterine involution?
- Contraction of muscle fibers to reduce those previously stretched during pregnancy
- Catabolism, which shrinks enlarged individual myometrial cells
- Regeneration of uterine epithelium from the lower layer of decidua after upper layers have been sloughed off and shed during lochial discharge
Approx 1 week after birth how much does the uterus shrink, end of 6 weeks??
During first 12 hours postpartum the fundus is at the level of?
The uterus typically descends from the level of umbilicus at rate of ______per day?
end of 1st week - 50% &1lb, end of 6 weeks 2oz
Umbilicus
1cm/day
*by end of 10 days cannot be palpated bc descended into true pelvis
What are factors that inhibit involution?
Prolonged labor, difficult birth, incomplete expulsion of amniotic membranes and placenta, uterine infection, overdistension of uterine muscles (multiples, hydramnios, large fetus), a full bladder, anesthesia, close childbirth spacing
Lochia
Define
Results from
Immediatley after childbirth -
Alkaline/acidic
Each day lochia should be
1.Vaginal discharge that occurs after birth and usually continues approx 4-8 weeks.
2. Results from involution during which a superficial layer of decidua basalis becomes necrotic and is sloughed off
3. bright red, consists mainly of blood, fibrinous products, decidual cells and red and white blood cells
4. Lochia from uterus is alkaline, becomes acidic from vagina
5. Each day should be less and color lighter
What is the primary mechanism preventing hemorrhage from placental site
Uterus begins to contract, constricting intramymetrial vessels and impeding blood flow
“afterpains”
*usually respond to oral analgesics
What will inadequate myometrial contractions result in
atony which will result in early postpartum hemorrhage
Why are afterpains stronger during breastfeeding?
Because oxytocin is released increasing the contractions
Immediately after vag birth what does cervix look like?
Extends into vagina, partly dilated, bruised and edematous
*returns to prepregnant state at 6 weeks.
*internal cervical os closes and returns by 2wkes
**External cervical os no longer a circle but a slit opening
How is vagina after birth?
Edematous, relaxed, thin with few rugae
As ovarian function returns and estrogen returns mucosa thickens and rugae return approx 3 weeks
What are comfort measures for swollen hemorrhoids
Ice pack
Pour warm water over area
which hazel pads
anesthetic spray
sitz bath
Cardiovascular system adaptations after birth
How is
Cardiac output
Blood volume
Hematocrit?
-C/o remains high few days then declines w/in 3 months
-Blood volume -Prepregnant w/in 4 weeks
-Hematocrit - relatively stable might even increase, reflecting loss of plasma
Why would a woman have a elevated temp up to 100.4 in the first 24hrs postpartum?
Due to dehyrdation.
Might also have a slight decrease in BP
The decrease in C/o is reflected in—– for how many weeks?
Bradycardia
first 2 weeks
What would tachycardia in post partum indicate?
hypovolemia
dehydration
hemmorhage
What changes affect BP after birth
Falls in first 2 days
increases 3-7 days
Returns to normal by 6 weeks
What could decreased bp postpartum indicate?
infection
hemorrhage
What places post partum women at increased risk for blood clots?
Hemostatsis that favor coagulation, reduced fibrinolysis, pooling and stais of blood
What can increase the risk of coagulation disorders?
SMoking, obesity, immobility, infection, bleeding, emergency surgery (c-section)
What happens to hemoglobin and hemotacrit in first 24 hrs post partum
decrease slightly
Over next 2 weeks rise slowly
When does urinary system return to normal post partum?
6 weeks
What is a major cause of uterine atony?
Urinary retention
What does urinary retention and bladder extension cause?
Displacement of uterus to the right and can inhibit contractions which increases risk of postpartum hemmorhage
What does freq amounts of less than 150ml of urine suggest?
Urinary retention with overflow
Catherterization may be necessary
What factors contribute to rapid filling of bladder wtihin 12hours after birth?
large amounts of IV fluids
decreasing antidiurtiec effect of oxytocin
build up of extra fluids during preg
decrease production of aldosterone (decreases sodium retention and increases urine production)
GI system adaptations
Why do women expierence decreased bowel tone and sluggish bowels post partum?
decreased peristalsis in response to analgesics, surgery, diminished intraabdominal pressure
low fiber
insufficient fluid intake
diminished muscle tone
Integumentary system adaptations
What is the purpose of postpartum diaphoresis
reduce amount of fluids retained during preg and restore pre preg levels
Respiratory system adaptations
When does respiratory volumes return to normal
1-3 weeks
Endocrine system adaptations
When is there a rapid clearnace of placenta hormones?
Decreased estrogen levels are assoc with?
When is estrogen the lowest?
Delivery of placents
-Breast engorgement, diuresis
- estrogen lowest 1wk after , non breast feeding - increase by weeks 2 / breastfeedign estrogen remains low
When is Progesterone levels undectable?
When is Hcg undectable?
When does prolactin decline?
Progesterone - 3 day
Hcg - 1 day
Prolactin - decline w/in 2 weeks
Lactation
Secretion of milk by breasts
Brought on by interaction of progesterone, estrogen, prolactin and oxytocin
Appears 4-5 days post
What are APP Recommendations for breast feeding
exclusive for 6 months
Intro foods w/ breastfeeding to 1 year+
What are the roles of the following in breastfeeding?
Estrogen
Progesterone
Prolactin
Oxytocin
Estrogen - stims growth of milk collection system
Progesterone- stims growth of milk collection system
Prolactin- triggers synthesis and secretion of milke after birth
Oxytocin - milk can be ejected from alveoli to nipple
The newborn sucking on breast stimulated what?
Pituitary gland to release PROLACTIN and OXYTOCIN
Engorgement
Postnatal physiologic painful condition in which distention and swelling of breast tissue occurs as result of increase in blood and lymph sypply as a precursor to lactation
Peaks 3-5days postpartum
Subsides 24-36hrs
What helps minimize discomfort for full breasts for a woman who is breast feeding?
Freq emptying
warm shower or compress
heat/cold
cabbage leaf
massage
antiinflam agent
What helps minimize discomfort for full breasts for a woman who is not breast feeding?
Wear tight supportive bra 24hrs
Apply ice 15-20 mins every other hour
Avoid sexual stimulation
not squeeze or express milk
*avoid warmth
Usually sibsides wtihin 2-3 days
What is taking-in phase
Time immediately after birth when pt needs sleep, depends on other to meet needs, relives events of birth
Characterized by dependant behavior / passive role
Allowing nurse to make decisons
Lasts 1-2days
Taking-hold phase
2nd phase of maternal adaptation, characterized by dependent and independent maternal behavior
*starts on 2nd or 3rd day and may last several weeks
_Preoccupied with present, concerns about her health, infants condition, and ability to care for baby. Begins to take charge
Letting go phase
3rd phase
Women reestablishes relationships with other people
Assumes parental role and separates herself from symbiotic relationship that she and newborn had during pregnancy
Establishes lifestyle with infant
To foster maternal role attainment what are 3 specific nursing interventions
- instructions about infant care and infants capabilities
- Mothers perfer live classes rather than videos
- Id barriers that reduce skin to skin contact
What does a postpartum assessment include?
BUBBLE-EE
Vital signs
Pain level
Epidural site inspection for infection
Systematic head to toe
Psychosocial assessment
Assessing parents and other family members
Use BUBBLE_EE
Breasts
Uterus
Bladder
Bowels
Lochia
Episiotomy.perineum/epidural site
Extremeties
Emotional status
Postpartum assessments typically are as follows
During first hour?
2nd hour?
First 24hrs after 2nd hour?
After 24 hours?
During first hour- q 15min
2nd hour - q 30 min
First 24hrs after 2nd hour- q 4hrs
After 24 hours - q 8hrs
What happens to moms temp postpartum?
Temp above 100.4?
Remains in normal range or low grade elevation up to 100.4 bc of dehyrdation
above 100.4 first 24hrs = infection, maternal sepsis
What happens to moms pulse postpartum?
60-80bpm for first week - called puerperal bradycardia
Elevated stroke volume after baby is out leads to lower HR
Puerperal bradycardia
pulse rate after birth 60-80bpm
What does tachycardia in post partum women indicate?
anxiety, excitment, fatique, pain, excessive blood loss, delayed hemorrhage, infection, underlying cardiac problems
bpm higher than 100 warrants further investigation
What happens to respirations to mom postpartum?
What does change in respiratory indicate?
Shoud be normal 12-20bpm
Change in respiratory indicates: pulmonary edema, atelectasis, pulmonary embolism
What happens to moms blood pressure postpartum?
Increase could indicate?
Decrease?
After birth BP should remain same as during labor
Increase in BP: gestational HTN
Decreae in BP: shock, orthostatic hypotension, dehydration
Should not be higher than 140/90
or lower than 85/60
How should nurses ease moms pain postpartum?
Aim for pain level?
5th vital sign
Ease pain: perineal care, clean gown, mouth care, warm blanket, adequate fluid, repositioning, rest, premedicate
Maintain pain at 0-2 at all times
What could it mean if a mom has severe pain in [erineal region despite use of comfort measures?
hematoma
Bonding
close emotional attraction to a newborn by parents that develops during first 30-60mins after birth
Attachment
Development of strong affection between infant and significant other (mother, father, sibiling, caregiver)
*influences view of world and future relationships
En face position
face to face while holding or feeding
Proximity
refers to physical and psychological experience of parents being close to their infant
What are the 3 dimensions of proximity?
Contact: sensory experiences of touch, holding, gazing
Emotional state: Affective expierences of new parents toward newborn
Individualization: Parents are aware of need to differentiate the infants needs from their own
Reciprocity
Process by which infants abilities and behaviors elicit parental response
What is complementary reciprocity
What is Sensitivity
Complementary - involves taking turns and stopping when other is not interested or tired
Sensitivity: parents who are sensitive to infants communication
What are recommended excersices for first few weeks postpartum
Abdominal breathing
Head lifts
Modified sit ups
double knee roll
pelvic tilit
When women are on what medication should they not breast feed?
Antithyroid
antineoplastic drugs
alcohol
active herpes infection on breasts
street drugs
HIV positive
What are other contraindications to breasfeeding a newborn
Galactosemia, PKU, active untreated TB, mother with serious mental health
How to alleviate breast engorgment when not breast feeding
Ice packs
Snug supportive bra for 24hrs a day
mild analgesics
avoid stimulation
uterine atony
loss of muscle tone
What could uterine atony place mom at risk for
hemorrhage
Neonatal period
first 28 days of life
What are the 4 interdependent areas the newborns most dramatic transitions occur
Circulatory
Respiratory
Thermoregulation
Ability to stabalize blood sugar
During first few mins of birth newborns HR is
and decreases to an avg of
110-160
120-130bpm
What newborns actions corresponds to increase in HR and BP
Increase in activity, wakefulness, movement, crying
What is newborn tachycardia found with
Bradycardia?
tachycardia - volume depletion, cardiorespiratory disease, drug withdrawl, hyperthyroidism
Bradycardia - apnea and hypoxia
What is the typical blood volume of a newborn and what does it depend on
approx 80-100ml/kg of body weight
depends on amount of blood transfered from placenta at birth
What do recent studies show as benefits of delayed cord clamping
improving newborns cardiopulmonary adaptation, preventing iron deficiency anemia, increaseing bp, improving oxygen transport, increasing RBC
What is the lifespan of RBC for a newborn
80-100 days compared to adutls 120 days
Surfactant
surface tension-reducing lipoprotein found in newborns lungs that prevent alveolar collapse at end of expiration and loss of lung volume
The first breath of life is a gasp that generates an increase in
transpulmonary pressure and results in diaphragmatic desent
What becomes stimuli for initiating respirations
hypercapnia, hypoxia and acidosis from normal labor
What must occur before newborns lungs can maintain respiratory function
Initiation of respiratory movement
Expansion of lungs
Esta of functional residual capacity (ability to retain air in lungs on expiration)
Increased pulmonary blood flow
Redistribution of cardiac output
After respirations are established, how are they in newborn?
RR?
30-60bpm w/ short periods of apnea and shallow and irregular
What are signs of respiratory distress in newborn
Cyanosis, tachycardia, expiratory grunting, sternal retractions, nasal flaring
Thermoregulation
Process of maintaining the balance between heat loss and heat production in order to maintain the bodys core internal temperature
What are several things that predispose newborns to heat loss
1Thin skin with blood vessels close to surface
2Increased skin permeability to water
3Lack of shivering ability until 3mo
4Limited stores of metabolic substrates (glucose, glycogen, fat)
5Large surface of area-to-body mass ratio
6Lack of subq fat
7Little ability to conserve heat by changing posture
8No abiltiy to adjust their own clothing or blankets
9Inability to communicate
Conduction
Transfer of heat from one object to another when two objects are in direct contact with each other
Convection
Flow of heat from body surface to cooler surrounding air or to air circulating over body surface
Evaporation
Loss of heat when a liquid is converted to a vapor
Sensible - objective and can be noticed
Insensible - individual not aware
Radiation
loss of body heat to cooler, solid surfaces that are in proximity but not direct contact
Where is the primary heat regulator located
hypothalamus and CNS
What does overheating do to fluid, respiratory rate and metabolic rate
Increases fluid loss, respiratory rate and metabolic rate
Thermoregulation is related to newborns rate of
Metabolism and oxygen consumption
Neutral thermal environment
Environment in which body temp is maintained without an increase in metabolic rate or oxygen use
Promotes growth and stability, conserves energy, minimizes heat and water loss
The newborns primary method of heat production is through
nonshivering thermogenesis
Process in which brown fat is oxidized in response to cold exposure
What does brown adipose tissue do
Convert chemical energy directly into heat when activiated by sympathetic nervous system
Produced during 3rd trimester
Where is brown adipose tissue found
Scapulae, axillae, nape of neck, mediastinum, areas surrounding kidneys, adrenal glands
When a newborn is exposed to cold what does the body do
NE is released
which stims brown fat metabolism by breaking down triglycerides
C/O increases = increasing blood flow through brown fat tissue
Blood becomes warmed as a results of increased metabolic activity of brown fat
Cold stress
excessive heat loss that required newborn to use compensatory mechanism to maintain core temp
-less active, lethargic, hypotonic, weaker
–at risk mostly 1st 12 hours
What problems can cold stress lead to in newborn
depelted brown fat, increased O2 and gluocse consumption, respiratory distress, depletion of glycogen = hypoglycemia, pulmonary vasoconstriction, metabolic acidiosis, jaundice, hypoxia and decreased surfactant production
What determins the iron status of a newborn at birth
Maturity, birth weight, hemoglobin level
Bilirubin
yellow-orange bile pigment produced by breakdown of RBC
Normally circulates in plasma, taken up by liver cells and changed to water soluable pogment that is excreted in bile
Newborns produce bilirubin at what rate per day
8-10mg/kg/day
twice the rate of adults, declines to adult level in 10-14days post birth
What causes jaundice
failure of liver cells to break down and excrete bilirubin causes an increased amount in bloodstream. Deposited in skin and mucous membranes as a result of the build up
yellowing of skin, eyes and sclera and mucous membranes
Bilirubin encephalopathy
permenent and devastating brain damage
What are common risk factors for developing jaundice
fetal-maternal blood group incomatibility
Prematurity
asphyxia at birth
insufficient intake of milk during breast feeding
drugs (diazepam, oxytoci, sulfisoxazole. chloramphenicol)
Maternal gestational diabetes\
infreq feeding
male gender
trauma at birth
intrauterine infection
asian or native american ethnicity
Meconium
composed of amniotic fluid, shed mucosal cells, intestinal secretions, and blood
greenish black, tarry consistency, usually passed within 12-24 hours after birth
After meconium is passed and feedings are initiated how are stools?
greenish-brown to yellow brown, thinner and seedy in appearance
Breastfeed - light mustard w/ seed like particles
Formula fed - tan/yellow firmer
When does renal cortex reach maturity in a newborn
12-18 months
What immunoglobin is able to cross placenta
IgG
Begining at 20-22wks
Produces antibodies against bacteria, toxins and viral agents
What is a major source of IgA
Breast milk
First period of reactivity
birth may last from 30 mins to 2 hours
Alert, moving and hungry’
Characterized by myoclonic movements of eyes, spontaneous moro reflexes, sucking, chewing, rooting, fine tremors/ Muscle tone and motor activity are increased
Period of decreased responsiveness
2nd stage
at 30 mins to 120mins of age,
period of decreased responsiveness, movements less jerky and less freq
HR and RR declines and newborn sleeps
Difficult to arouse
2nd period of reactivity
Awakens and shows interest in environmental stimuli
lasts 2-8hrs
Hr and Rr increases
Peristalis also increases
Meconium or void during this period
Neurobehavioral responses
how newborns interact with world around them
Orientation, habituation, motor maturity, self-quieting ability, social behaviors
How does orientation reflect in newborns
Response to auditory and visual stimuli demonstrated by their movements of head and eyes to focus on stimulus
Habituation
newborns ability to process and respond to visual and auditory stimuli
How well infant responds to environment
ability to block out external stimuli after becoming accustomed to activity
useful indicator of neurobehavioral intactness
Motor maturity
involves evaluation of posutre, tone, coordination and movements
*bringing hand up to mouth
Why are we checking for protein in urine at prenatal visits?
When BP is out of control kidneys will throw out protein
How long during breastfeeding does mom take prenatals and folic acid
1 month after breastfeedings
what increase in cal does a breast feeding mom need
330 cal +
What are the 7 cardinal movements of labor and delivery?
a. Engagement.
b. Descent.
c. Flexion.
d. Internal rotation.
e. Extension.
f. Restitution and external rotation.
g. Expulsion.
[Mnemonic for memory is: Every day fine infants enter eager and excited
