OB Module 1: Part 1 - Postpartum Flashcards
When do all babies get full assessments (at the very least)?
Immediate assessment by nurse and doc at birth, and then again by doc before discharge
What are the 4 areas of the OB Unit?
Labor and Delivery
Postpartum
The Nursery
Neonatal Intensive Care Unit (NICU)
Birth is a life event for a woman where she is …
in a very vulnerable point in her life
It is important that the OB nurse by ____ of how different women cope with extreme pain
non-judgmental
Post partum women need to ___ their birth experiences ____ so that they can do what?
Post partum women need to recount their birth experiences verbally so that they can start to put these experiences into perspective and get on with the work of taking in their infant and mothering
The more ___ the birth, the more they need to recover from
traumatic
Everytime an infant is taken to a mother what must be done?
Sequential numbered ID bracelets are checked
The infant has 2 on and the mother has one while she designates another person to have the fourth bracelet
What assessments are included in postpartum care?
Physical assessments
Interactions w/ and care of infant
Support systems available
Pain Level and coping strategies
Educational needs
VS and BP
BUBBLE Assessment
BUBBLE Assessment
B - Breasts
U - Uterus/Fundus
B - Belly
B- Bottom
L - Lochia
E - Edema/Homans
What are we looking at in the first B of BUBBLE
Breasts for filling, nipple status and engorgement (rare)
What are we looking at in the U of BUBBLE
Uterus/Fundus in relation to the umbilicus
What are we looking at in the second B of BUBBLE
Belly - Abdominal incisions, bowel sounds, distention, elimination, voiding, and bowels in general
What are we looking at in the third B of BUBBLE
Bottom - check perineum for aswelling, ecchymosis, hematomas, lacerations, episiotomies and the status of repairs, hemorrhoids
What are we looking at in the L of BUBBLE
Lochia vaginal flow
What are we looking at in the E of BUBBLE
Edema - Edema and Homans sign
if the policy is to check Homans, some places do not like at Lourdes Hospital
What are two important considerations regarding VS and BP in reference to a pregnant woman’s post partum circulating blood?
- VS and BP reflect hemodynamic status, but unlike a nonpregnant person, the pregnant woman can lose 30% OF CIRCULATING BLOOD before there are perceivable changes in VS
- A woman can lose 50% before there are significant changes. Women who are anemic prior to labor will be affected with smaller loses!
Anemia
Preeclampsia
A potentially life threatening complication of pregnancy
Blood pressure elevations related to this that START in the post partum period
*Elevations in BP are unusual
What BP and higher is significant in the mother and should trigger initiation of additional and ongoing assessments?
140/90 and greater
*Elevations in BP in this group are unusual
What sort of temperature changes are concerning in the post partum period and what are not?
Elevations could be infection, but LOW GRADE FEVER changes are common when milk “comes in” or is secondary to dehydration in the immediate post partum period
Temperatures above 100.4 are indicative of infection
Endometritis
infection of the uterus often secondary to an infection that develops in the uterus during labor (chorioamnionitis).
If a womans water was broken for >24 hours the risk of developing this infection increases
What infection is Endometritis often secondary to?
Chorioamnionitis
In the post partum period, elevations in pulse and temperature rates could be related to ___ ___ or ___-
blood loss or infection
Shortness of Breath and Syncope are indicators of what in the post partum period?
Significant blood loss
What is included in the group of post partum lab work?
H&H
Review of Rubella Status and administering the vaccine if negative or equivocal
Review of Rh status and administration of Rhogam if the mother is Rh negative and infant is rh positive
Review of hepatitis status and immunization of the infant if HepB positive
Some lab values differ in pregnancy!
What is done if a Rubella status comes back as negative or equivocal for a post partum woman?
She is given the vaccine, but because it is a live vaccine it is important that she NOT GET PREGNANT FOR THE NEXT 3 MONTHS
What is done if the post partum woman comes back as Hep B positive?
The infant must be immunized immediately
The post partum period starts at what time and continues for how long?
Starts at the delivery of the placenta and continues for approximately 6 weeks as the reproductive organs return to their normal non pregnant state
In addition to undergoing significant physical recovery what else must the new mother do?
Put her birth experience into perspective and transition into the role of caregiver for her new infant
___ relating to self care and infant care are important components of the post partum care plan!
Education
What are the immediate post partum changes that occur in the woman?
Uterine and Cervical Involution
Lochia Flow
decrease in Vaginal distention
Breast changes
urinary changes
GI changes
Cardiovascular changes
Endocrine changes
Uterine Involution
Process by which the uterus is transformed from pregnant back/collapses back to the non pregnant state
Period is characterized by restoration of ovarian function in order to prepare for any new pregnancies
Cervical Involution
shrinkage of the cervix back to a pre pregnancy state
Lochia
Vaginal discharge after giving birth, containing blood mucus and uterine tissue
Continues about 4-6 weeks post partum
Every day in 2017, about 810 women died from, ____ causes related to pregnancy and childbirth
preventable
Between 2000 and 2017, the maternal mortality ratio (MMR) dropped by about 38% ___, but the MMR rates are increasing in ___
worldwide; the U.S.
94% of all maternal deaths occur in what countries?
Low and lower middle income countries
MMR
Maternal Mortality Ratio
Number of maternal deaths per 100,000 live births
What group faces a higher risk of complications and death as a result of pregnancy when compared to other women?
Young Adolescents (ages 10-14)
Skilled care ___, ___, and ___ childbirth can save the lives of women and newborns
before, during, AND after
What are some common reasons for pregnancy related deaths in the US (2011-2016)?
Hemorrhage, 11.0%.
Infection or sepsis, 12.5%.
Amniotic fluid embolism, 5.6%.
Thrombotic pulmonary or other embolism, 9.0%.
Hypertensive disorders of pregnancy, 6.9%
Anesthesia complications, 0.3%.
Cerebrovascular accidents, 7.7%.
Cardiomyopathy, 11.0%.
Other cardiovascular conditions, 15.7%.
Other noncardiovascular medical conditions, 13.9%.
Any pregnant woman is in a ___ state, leading to high clot risk
hypercoagulable
Why is cardiomyopathy related pregnancy deaths on the rise?
Because of many women in the US being heavy set during pregnancy
Amniotic Fluid Embolism
Clot that forms after amniotic fluid is swept up into maternal circulation
Uterine Involution starts when and continues through when?
starts in delivery but continues through the post partum period
After Cramps
The uterus continues to contract after delivery. There are dilated blood vessels flow through the muscle fibers of the uterus, so the uterus will contract in a “tourniquet like effect”. These contractions are the after cramps
More noticeable the more pregnancies a woman has
The more contractions = more after cramps felt too
What is the number 1 cause of maternal death in the world and accounts for 27% of all maternal deaths worldwide?
Postpartum hemorrhage
Immediately after expulsion of the placenta, the top of the fundus is …
in the midline and approximately halfway between the symphysis pubic and the umbilicus
After 6-12 hours post partum, where is the fundus?
the highest point of the uterus, the fundus, is usually located at the umbilicus
Feels like a grapefruit in the abdomen
The height of the fundus after 6-12 hours post partum decreases…
about one finger breadth (about 1 cm) each day back to its normal position
It will feel hard like a baseball
If the uterus is above the umbilicus after 6-12 hours, be concerned that it is not what?
well contracts and blood flow may increase
The more distended the uterus has been during pregnancy, the more…
difficult it is for it to contract effectively after delivery
Because of this women who have multiple infants and those that have large infants ARE AT INCREASED RISK FOR HEMORRHAGE
A ___ ___ can interfere with effective post partum uterus contraction
distended bladder
What does it mean if the fundus is pushed to the right and is above the umbilicus?
The bladder is full (and making it compete for space)
Like the uterus, the ___ and ___ involute after delivery
the cervix and vagina
Why do the cervix and vagina have to involute after birth?
they dilated to allow passage of the infant and need to return to pre pregnancy state
Why is it so important the cervix close?
to prevent infection having access to the uterine cavity
How long does cervical and uterine involution take?
process takes up to several weeks to comp[lete
Kegal Exercises
exercises to assist with restoring vaginal tone
Vaginal flow after delivery is usually representative of what?
the shedding of the uterine lining and the oozing from the site of placental implantation
Atony
lack of tone
Excessive post partum bleeding can come from…
Uterine atony
Unrepaired cervical, vaginal or perineal lacerations
Retained placental fragments (lead to bad uterine contraction/involution)
Vaginal or Vulvular Hematomas
Coagulopathies
types of Lochia
Lochia Rubra
Lochia Serousa
Lochia Alba
Lochia Rubra
Initial lochia that is red in color
Occurs 1-3 days post pregnancy
What does brighter red or darker mahogany colored Lochia Rubra Mean?
The brighter red the flow, the fresher the bleeding
Darker more mahogany colored bleeding means older bleeding that collected in the vagina and uterus and was expressed now (not necessarily bad)
What kind of lochia flow is common 1-3 days after delivery with position changes?
large amounts of very dark flow
Lochia Serousa
a serousy and pinkish brown color vaginal discharge
Occurs 4-10 days post delivery
Lochia Alba
A yellowy white color lochia
Has a distinctive fleshy odor
Occurs 11 days to 6 weeks post delivery
It is a NORMAL DISCHARGE
Lochia is often accompanied by ___ ___
blood clots
What are the five different amounts of documented lochia measurement?
Scant
Light
Moderate
Heavy
Excessive
What amount of lochia is scant
less than 2.5 cm on the pad
What amount of lochia is light
less than 10 cm on the pad but more than 2.5 cm
What amount of lochia is moderate
greater than 10 cm on the pad
What amount of lochia is heavy
saturating a pad every 2 hours
What amount of lochia is excessive
saturating a pad every 15 minutes and/or pooling of blood under the buttocks
Breast changes in the post partum period can happen ___ or ___ the woman intends to breastfeed
whether or not
For the first __ to ___ days after birth, breasts secrete ___
1-3 days; colostrum
Colostrum
a dense yellowish fluid rich in protein, fat, and antibodies
Secreted by the breasts for the first 1-3 days post birth
Between what time period will mature milk start to “come in”
between the 2nd and 5th day
When the mature milk “comes in” how may the breasts feel?
May feel hard and full (potentially engorged).
When the breasts are full they may even feel lumpy
Milk in the ducts may feel like cottage cheese in a bag
Nipple Trauma
Trauma occurring to breastfeeding mothers who are not doing preventative measures
The nipples blister and crack which impedes feeding because of discomfort and can create an entry port for bacteria and leave the woman at risk for developing mastitits
What things can a breastfeeding mother be educated on to prevent nipple trauma?
Making sure the infant latches well every time (the most important measure)
Changing start side (to equalize pressure of suction)
Changing positions
Do not wipe off after secretions
Air exposure after feeding
The breastfeeding mother can breastfeed how many times a day and for up to how long?
Could go 8-12 times a day each at up to an hour at a time
The best prevention and treatment for breast engorgement in the breastfeeding mother is ___ ___
frequent breastfeeding
For the non nursing mother, prevention of engorgement is important too, what can they do to prevent engorgement?
Instruct to wear a snug fitting bra immediately after delivery and to continue wearing it
She can also use ice pack and raw cabbage leaves lining the bra to impede milk production
Do not have the breasts stimulated as well
Milk production is what kind of system?
A supply and demand system
We want frequent breastfeeding to stimulate milk production and establish a supply in the breastfeeding mother while having a snug bra, ice, leaves, and no stimulation in the non breastfeeding mom to stop production
What are the urinary changes that occur in post partum?
Increased diuresis because of reduced estrogen
Increased space available in the pelvis
Potential for urinary retention, especially in vaginal deliveries related to swelling and birth trauma
A post partum woman should void by ___ hours and at least ___ cc
8 hours and at least 150 ccs
If a post partum mother is unable to void, she should be …
straight catheterized
GI changes in the post partum woman include ___ motility because of decreased ____
increased motility because of decreased progesterone
Another GI change in a post partum woman is decreased ___ and ___ of the stomach and bowel
decreased pressure and displacement of the stomach and bowel
C-Section patient’s will have ___ motility initially, thus making ___ ___ ___ a common practice
C section patients will have decreased motility initially, thus making gradually resuming feedings a common practice
Why is there a significant drop in estrogen and placenta post partum?
These extra hormones were made by the placenta which is now gone
Diastasis Recti Abdominis
A separation of the rectus muscles of the abdomen common after pregnancy
Why do we want a post partum mom to avoid aggravating exercise routines?
There is diastasis recti abdominis occurring which can cause herniation issues
Cardiovascular changes in the post-partum mother include…
- Blood loss during delivery
- Diuresis and Diaphoresis in the first 3 days
- potential for shock
- Diverting blood from the placentae
- Rapid reduction in uterine size allowing the return of blood flow systematically
- Continuation of the hypercoagulable state
Why is there potential for shock in a post partum woman?
shock potential is related to blood loss in delivery
How much blood is diverted back to systemic circulation from the placenta after delivery?
500-750 cc
Many of the mother’s post partum cardiovascular changes are due to what?
The fact she took on a lot of fluid which now needs to leave the body
What are the 3 major endocrine changes in the post partum woman?
- Oxytocin increases (from contractions and breastfeeding)
- Decreased estrogen, progesterone, and placental enzyme insulinase with the passing of the placenta
- Prolactin level increases
Oxytocin
Hormone released from the pituitary gland
It coordinates uterine contractions but is also the “Love” hormone and stimulates breast feeding and milk release
It is released for amourous attraction but also biochemically primes the mother to fall in love with the baby
What hormones increase with breastfeeding?
Prolactin and Oxytocin
Average blood loss with a vaginal delivery is ___ ccs or less
500
Average blood loss with C section delivery is ___ ccs or less
1000
When are post partum hemorrhages considered early? When are they considered late? Which is more common?
early - within 24 hours of delivery
late - after 24 hours but can occur up to 6 weeks later
Early partum hemorrhages are more common
Why is it important the the mother very gradually resumes her daily activities over the course of several weeks?
so that she is not at risk for a post partum hemorrhage
Women who have already made the transition in roles with a prior pregnancy must…
take in and expand their role as a parent
Women who are assuming the role of the mother for the first time…
have very significant role changes
complex role strain can occur
Role adaptation as a new mother will include…
Accepting role as mother
Changing relationship dynamic with partner
changing relationship with extended family
“Bonding” to infant
Body image changes
What are the 3 major phases of role adaptation for the new mothers?
- taking in
- taking Hold
- Letting go
Taking In Phase of role adaptation
First couple of days
Passive dependent behaviors as she relies on other for help and guidance
Will repeat the birth story over and over
Taking Hold Phase of role adaptation
Lasts 2-10 days to several weeks
Asserts her independence as the primary caretaker of her infant
May verbalize fatigue, insecurity in skills, needs for nurturing and acceptance
Optimal time for teaching!!!!
Prone to depression
Commonly discharged at this stage
Letting Go Phase of role adaptation
She assumes her position at home and adjusts to her role
Focus is on the forward movement of her family unit
Reestablishes her relationship with her partner and may resume intimacy
Still prone to fatigue and depression
4 Stages a Woman Progresses through to establish a maternal identity
- Commitment
- Acquaintance/Attachment
- Moving toward
- Achievement of a maternal identity
Commitment Stage of Maternal Identity
Stage 1
Attachment to the unborn baby, and preparation for delivery and motherhood during pregnancy
Acquaintance/Attachment Stage of Maternal Identity
Stage 2
Acquaintance/Attachment to the infant, learning to care for the infant, and physical restoration during the first 2-6 weeks following birth
Moving Toward stage of Maternal Identity
Stage 3
Moving toward a new normal
Achievement of a Maternal Identity stage of Maternal Identity
Stage 4
Achieves maternal identity through redefining self to incorporate motherhood (around 4 months).
The mother feels self confident and competent in her mothering and expresses love for and pleasure interacting with her infant
Ways to Promote Infant Bonding
Allow contact
Allow mom to undress the infant (take in baby fully)
Encourage “en face” positioning
Have mom recognize infant as a unique individual
Have mom recognize infant characteristics with different family members
Have mom touch, hold, and maintain proximity to infant
En Face Positoning
Mother puts face directly in front of baby for eye to eye contact
Behaviors to watch for an hope to see between mother and infant?
- responds to cues from infant and provides care
- Smiles at and talks to infant
- Communicates pride in infant
- Assigns meaning to the infants behavior and views them positively
Potentially pathological signs to watch for between mother and infant?
- Apathy A(turns away from infant, does not seek proximity)
- Disgusts in infant bodily functions, methodical care, and ignores infant
- Views infants behaviors as deliberatively uncooperative or disruptive
4.Expresses disappointment in the infant, does not talk about the infants unique features
- Handles infant roughly
- Lack of preparation for the infant
Engrossment
Process of the partner that is characterized by seven behaviors - this differs slightly from the moms process
- Visual Awareness of Newborn
- Tactile Awareness of Newborn
- Perception of the newborn as perfect
- Strong attraction to the newborn
- Awareness of distinct features of the newborn
- Extreme Elation
- Increased sense of self esteem
Visual Awareness of the Newborn during Engrossment of the Partner
The father perceives the newborn as attractive, pretty, or beautiful
Tactile Awareness of the Newborn during Engrossment of the Partner
the father or partner has a desire to touch or hold the newborn and considers this activity to be pleasurable
Mother to infant contact is just as important as father to infant contact in first few hours
Perception of the newborn as perfect during engrossment of the partner
the father or partner does not “see” any imperfections
Strong attraction to the newborn during engrossment of the partner
the father or partner focuses all attention on the newborn when he is in the room
Awareness of distinct features of the newborn during engrossment of the partner
the father or partner can distinguish his newborn from others in the nursery
Extreme elation during engrossment of the partner
the father or partner feels a “high” after the birth of his child
“I never expected the intensity of how I feel about him/her”
Increased sense of self esteem during engrossment of the partner?
the father or partner feels proud, “bigger”, more mature, and older after the birth of their child
Common Complications of the Post Partum Period
Hemorrhage
Infection
Thromboembolic Disease
Postpartum Psychiatric Disorders
What are the risk factors for the common complications of the post partum period?
Over distention of uterus due to large baby, multiple gestation, multiparity
Rapid or prolonged labor
Oxytocin induction of labor
Precipitous induction of labor
Precipitous delivery, cesarean section (3 hours or less)
Prolonged or premature ROM
Urinary catheterization (always done in C Sections)
What are the 6 factors associated with development of Mastitis?
Milk stasis
Promotion of access/multiplication of bacteria
Breast/nipple trauma
obstruction of ducts
change in number of feedings/failure to empty breasts
lowered maternal defenses
What contributes to milk stasis?
failure to change infant position for lobe emptying
failure to alternate breasts when feeding
poor suck
poor letdown
What contributes to the promotion of access/multiplication of bacteria causing mastitis?
poor hand washing
improper breast hygiene
failure to air dry breasts after feeding
use of plastic lined breast pads that trap moisture
What contributes to breast/nipple trauma that causes mastitis?
poor latch
incorrect positioning
aggressive pumping
failure to rotate position on the nipple
What contributes to obstruction of the ducts which can cause mastitis?
restrictive clothing
constrictive bra
underwire bra
What contributes to the change in number of feedings/failure to empty the breasts?
attempted weaning
missed feedings
prolonged sleeping, including sleeping through the night
feeding primarily from one side because of nipple soreness
What contributes to lowered maternal defenses
fatigue
stress
S/S of Hemorrhage complications in the Post Partum Woman
Vaginal bleeding
Persistent bleeding in the presence of a firmly contracted uterus
Rise in the level of the fundus in the abdomen, uterine atony, “boggy” uterus
Abnormal clots
Unusual pelvic discomfort or backache
Increased pulse, decreased BP, lightheadedness, syncope, SOB
Hematoma formation or shiny bulging skin in the perineal area
Decreased level of consciousness
Lowered hemoglobin and hematocrit results
Is a lemon sized clot normal in the first few hours after delivery?
Yes a clot this large may be delivered after a few hours, but anything larger or more frequent means a poorly contracted uterus
S/S of Infection complications in the post partum woman?
fever
purulent discharge from vagina or incision
erythema at incision site
increased WBCs
burning during urination
redness/pain in breast about fourth postpartum week
S/S of Blood clots in the post partum woman?
positive Homans sign
skin color changes
pain
tenderness
swelling in lower extremities
S/S of Depression in post partum woman?
overwhelming sadness
low self esteem
lack of desire to care for the child
It is important to keep in mind what things about WBC levels in post partum?
WBCs above 20 have a cause (infection), but an increase of WBC after birth for a bit is normal
Where are blood clots commonly forming in the post partum woman?
In the pelvis, thighs, or calves
Postpartum blues usually subside after…
2 weeks
Factors associated with increased risk of thromboembolic disease in the post partum woman
C Section
Inactivity
Obesity
Cigarette Smoking
Previous thromboembolic disease
Trauma to the extremity (may be related to positioning during labor and delivery)
Varicose veins
Diabetes
Advanced maternal age
Inherited thromboembolic disorders
Multiparity
Anemia
Why do C Sections make a woman more prone to thromboembolic disease?
It makes them more hypercoagulable on top of the state they are in in pregnancy, and they are more inactive and confined to bed
Most women (___%) experience a transient period of ___ depressive symptoms in the first ___ weeks after delivery
most women (80%) experience a transient period of mild depressive symptoms in the first two weeks after delivery\
This is post partum blues
About ___% of women will experience ___ symptoms of depression that usually set in later in the post partum period. This is called __ __ depression
about 15% of women will experience severe symptoms of depression that usually set in later in the post partum period. this is called post partum depression
Post Partum Psychosis
A small percentage of woman develop this more severe psych issue
It requires a period of in hospital evaluation, stabilization, and treatment
Observe the new mother for ___ signs or depression, listen for feelings of ___ and __ ___
observe the new mother for objective signs of depression, listen for feelings of failure and self accusation
If the mother feels overwhelming feelings of sadness or inability to care for the infant what should the nurse do?
Provide a list of support organizations in the community
Women with post partum depression usually need…
to be on medication for 6 months and often benefit from therapy
What puts a woman at increased risk for post partum depression?
A history of depression in the past
When is post partum depression more severe?
In first time mothers, rather than women who have had children before
Primiparas
A woman who has given birth to 1 child or who is giving birth for the first time
Multiparas
A woman who has had 2 or more pregnancies resulting in viable offspring
What observations may be made in a woman with post partum depression, especially a first time mother?
episodic tearfulness
Note if mother feels overwhelmed
inability to cope
fatigue
anxiety
irritability
oversensitivity
What are some factors that influence (positively or negatively) a woman’s success in physical healing and role changes during the post partum period?
General health and comfort level
Physical strain her labor created
her perceptions of her birth experience
relationship with her partner
relationship with her mother
social support available to her
her ability to rest in the first few weeks
nutrition
