Powerpoints Test 2 Module 4 Flashcards
Begins immediately after birth and continues for approximately 6 weeks or until the women’s reproductive system returns to its pre-pregnant state.
Postpartum
Postpartum nursing interventions
Bonding: encourage patients to see, hold, and touch their newborn
>Taking in: focus is caring for self
>Taking hold: focus is on caring for the baby
>Letting go: focus is on the family unit
•Postpartum “Blues” vs. Postpartum depression
Uterus-
? is the retrogressive return to normal condition after pregnancy
Immediately after delivery what should you see:
•involution
-Fundal height is midway
•Afterpains
•***Non-Pregnant 2 oz/2 lbs 4 oz
Factors that affect involution
Slow?
Enhanced ?
Slow Involution •Prolonged labor •Anesthesia or excessive analgesia •Difficult birth •Grand multiparity •Full bladder •Incomplete expulsion
Enhance Involution •Uncomplicated labor and birth •Complete expulsion •Breastfeeding •Early ambulation
Normal involution of the uterus each day
- The height of the fundus then decreases about one finger breath (approximately 1 cm) each day.
- 14 Days~ not palpalable
How to assess a fundus
Check for
- Consistency
- Position
- Height
- Tenderness
The uterus rids itself of the debris remaining after birth through a discharge called what?, which is classified according to its appearance and contents.
Lochia
The composition of lochia is made up of:
Endometrial tissue
•Epithelial cells
•Erythrocytes
•Leukocytes
How should you have rubra (red) discharge after birth?
What should It look like ?
When to know it’s abnormal?
1-3 days
Bloody & clots Increased flow: - breastfeeding - standing - physical activity
Foul Smell
Large clots
Quickly
saturates pad
How should you have serosa pink/brown discharge after birth?
What should It look like ?
When to know it’s abnormal?
3-10 days
Blood & mucous consistency
Foul Smell
Large clots
Quickly saturates pad
How should you have alba white/yellow discharge after birth?
What should It look like ?
When to know it’s abnormal?
10-14 days or longer
Mostly mucous
No strong odor
Foul Smell
Red/pink
Lochia return
How to assess ones pad/lochia after giving birth
Assessment
•Type & Amount
•Presence of odor
•Presence of clots
Scant amt - 1inch
Light-4 inches
Moderate-6inch
Heavy -heavy in 1 hour
Assessment of Perineum
REEDA
- R-redness
- E-edema
- E-ecchymosis
- D-drainage
- A-approximation
Breast Care:
Lactating Mother
Keep breasts clean and dry (use breast pads as needed)
•Report sore or cracked nipples to lactation nurse
Breast Care: Non-Lactating Mothers
Firm, supportive bra for 3-4 days
•Apply cold compress for 15 minutes as needed
•Clean, raw, green cabbage leaves for swelling or discomfort
•Pain medicine as needed
•Do not massage or apply heat to the breast
•Educate on Comfort Measures, such as ice packs and ibuprofen
•Discuss breast engorgement and breast pads for leaking
Normal immediate weight loss after birth
Immediately weight loss?
•afterbirth is 13 pounds, which accounts for the fetus, placenta, and amniotic fluid
- Loss of extra-cellular fluid weight loss?
- leads to an additional loss of 5 to 15 pounds during the puerperium.
What may cause difficulty voiding after birth and when should it diminish
Effects of anesthesia or trauma to the bladder from delivery may prevent the bladder from emptying completely.
Effects of trauma to the urethra and bladder should typically diminish in 24 hours.
Nursing interventions for bladder emptying
I&O for 24 hours post •Void every 3-4 hours. •Voiding at least 150 ml. •Unable to void at 6 hours post-delivery •Foley catheter should be left in place if more than 700ml output, prevention of hypotension post bladder decompression. •Peppermint oil in the toilet
How much blood one looses vaginally and c-section?
Increase in circulating blood volume during pregnancy
- Blood loss:
- vaginal delivery ~ 500 mL
- cesarean delivery ~ 800 and 1000 mL.
•Due to the increase in circulating blood volume during pregnancy, blood loss at delivery can be managed in normal healthy person.
Reason for diuresis (urge to urinate) after pregnancy
Excess fluid
3000 mL of fluid per day
Diaphoresis
GI assessment after birth
What GI risks do one have after birth?
Assess bowel sounds, distention, and flatus
•Effects of anesthesia, medications (magnesium sulfate, and narcotics), hemorrhoids, episiotomy, lacerations, dehydration, immobility, and fear of pain place the mother at risk for constipation.
•Gaseous distention can occur for 2-3 days follow birth from a decrease in gastric mobility and muscle tone, and relaxation of the abdominal wall.
Normal GI output after birth
Fears of postpartum mom and GI and birth?
Constipation can occur from the lack of fluid and food intake during labor
- Bowel tone is sluggish as a result of elevated progesterone levels.
- Often patients are hesitant to have a bowel movement due to pain in the perineal area that is cause by an episiotomy, lacerations, or hemorrhoids.
- Some patients are also fearful that they will rip their stitches during a bowel movement.
Postpartum constipation prevention
Discuss fears about sutures and perineal changes
•Advise early and frequent ambulation
•Discuss side effects of medications
•Encourage drinking 6-8 glasses of water/day
•Eating high fiber diet
•Sitz baths for pain management and topical anesthetics to help control perineal pain.
•Normal bowel activity returns 2-3 days postpartum.
Hemorrhoid statistics in postpartum women
•In a prospective study of 165 pregnant women
- 7.8% experienced thrombosed external hemorrhoids in late pregnancy
- 35% experienced anal lesion in the postpartum period
- 20% thrombosed external hemorrhoids in the postpartum period
- 15% anal lesions in the postpartum period.
•91% of these women had hemorrhoids on their first postpartum day. **
Hemorrhoid education in postpartum women
Avoid straining during bowel movements.
•Drink plenty of water and eat a diet high in fiber.
•Take stool softeners as advised by your provider.
•Walking helps with normal bowel elimination.
•Narcotic medications may contribute to constipation.
Why anal incontinence occurs after birth
The most common cause of fecal incontinence in healthy women is childbirth trauma.
•Mechanical disruption in the anal sphincter
•Damage to the nerves
- Rectovaginal fistula can occur after episiotomy breakdown, increased with 3rd and 4th degree lacerations.
- Anal sphincter damage may not manifest until years following childbirth.
Anal Sphincter Repair and education regarding future pregnancies
Women who have undergone secondary repair of the anal sphincter should be counseled regarding future pregnancies and vaginal deliveries.
•Experts advise that women who have had damage to their anal sphincter, should opt for a planned cesarean birth.
What happens to ones diaphragm (respiratory) during and after pregnancy
As the diaphragm raises near term
•thoracic rather than abdominal breathing in the third trimester
•The diaphragm descends following delivery and the postpartum breathing returns to the pre-pregnant state.
separation of abdominal muscles
•Diastasis Recti
What happens to ones muscle tone after pregnancy
education
- The abdominal wall is weakened and the muscle tone is decreased after pregnancy.
- Patients should be instructed to perform light abdominal exercises to regain abdominal tone to improve the separation.
Telogan effluvium
When it goes back to normal?
• Normal hair patterns return in 6 to 15 months after delivery.
Hair loss
To Who and when is the flu vaccine recommended to
Recommended October through April
- Women who will be pregnant during influenza season
- Caregivers of children from birth to age 5
- Health care workers
Rhogam injection
When and how it’s administered
side effects
IM injection
- Administered around 28 weeks gestation in the clinic
- Administer within 48 hours after delivery
- Side effects:
- Irritation at injection site
- Fever
- Lethargy
made up of antibodies called immunoglobulin, that help protect a fetus from its mother’s antibodies. It prevents the Rh-negative mother from making antibodies during her pregnancy.
Rhogam injection
Types of postpartum pain
Most patients experience some discomfort
- Causes of discomfort include:
- Episiotomy or laceration repairs
- Hemorrhoids
- Afterpains or cramps
- Breast engorgement
- Cesarean incision site pain
- Gas pain
- Postpartum Uterine Infection
- Right Shoulder pain after C-Birth or Tubal Ligation
Postpartum Pain interventions
Eliminate or reduce pain to tolerable level
•Use pain medications as needed, and as prescribed •Alternative comfort measures -K-pad -Massage/touch -Guided imagery -Movement (walking for gas pains) -Ice pack -Breathing exercises -Relaxation -Sitz baths
Postpartum fever-
First day vs 24 hours
Nurse should be aware of what?
First postpartum day
- > 101.0 F (38.3 C)
- Dehydration effects
- > 24 Hours
- > 38 Degrees Celsius (100.4 F) after the first 24 hours.
Important to Note:
Nursery staff should be made aware of maternal temperature.
Blood from severed vessels of placenta may cause
Pph
Postpartum hemorrhage
Risk factors for postpartum hemorrhage
- Antepartum
- Pre-Eclampsia
- Multiparity
- Multiple gestation
- Previous PPH
- Previous C-section
- Intrapartum
- Pitocin augmentation/induction
- Prolonged third stage
- Instrument assisted vaginal delivery
- Shoulder dystocia
- Episiotomy/laceration
S/s of postpartum hemorrhage
Copious vaginal bleeding •Increased abdominal girth •Persistent unrelieved pain •Tachycardia, early sign •Tachypnea •Hypotension, possibly late sign •Lightheadedness and/or dizziness •Pallor (pale skin) •Cool clammy skin •Oliguria (less than 30ml of urine per hour)
Postpartum hemorrhage causes
Think of 4 T’s
- Tone- uterine atony – most common
- Trauma- Laceration/inversion
- Tissue- Retained placental tissue
- Thrombin- Depleted coagulation factors
****Iatrogenic •Oxytocin induction or augmentation •Forceps or vacuum extraction •Magnesium Sulfate •Distended bladder
PPH- retained placenta -
How long is considered retained?
Treatment?
Failure to deliver placenta after 30 minutes
- Treatment
- Gentle cord traction
- Manual extraction
- Consider dose of antibiotic therapy after
- Find cleavage plane b/t placenta and uterus
- Advance fingertips cleaving the placenta free
- If no plane, consider placental insertion problem and need for the OR
- May need additional pain management if no epidural/spinal
- Consider injection of 20 units of Pitocin in the umbilical vein
PPH- uterine inversion
Cause and tx?
Rare
•Cause: Uterine atony/congenital weakness/cord traction
Tx-
•Prompt recognition is key
•Do not remove placenta
•Use your fist to replace the uterus
•Uterus not replaceable due to contraction ring
•Use Nitroglycerin or terbutaline
•If fails, go to OR for general anesthesia
Pph
Uterine atony
What is it ?
Common?
Hypotonia of the uterus
- The placenta circulates 750-1000ml of blood every minute, therefore, failure of the uterus to contract after placental separation can result in a significant blood loss.
- Accounts for 80% of all hemorrhages
Pph prevention
Management of anemia in pregnancy
- Appropriate labor management
- Appropriate patient selection for induction
- Third stage management
- Initiate Pitocin immediately after infant delivery
- Fundal Massage
•PPH is one of the few obstetric complications with an effective preventive intervention. ***
Pph treatment
Pitocin – begin after delivery of infant
- Massage uterus
- Inspect vaginal vault/cervix/placenta
- EMPTY BLADDER!!!!!
- Methergine 0.2mg IM every 15min x 3 doses
- Contraindicated in HTN disorders
- Hemabate 0.25mg IM every 15min x 5 doses
- Contraindicated in reactive airway disease
- Misoprostil 1000mcg PR x1
Pph general management
Fundal massage, support lower uterus while massaging fundus.
- Weigh pads
- Assess VS q 5-10 minutes until stable
- Apply pulse oximeter-administer oxygen per facility protocol
- I & O-insert indwelling
- Pain assessment- administer medications
- Elevate patient legs 20-30 degree to increase venous return
- Have tamponade balloon and resuscitation equipment ready
Pph drug therapy
- Oxytocin
- Methylergonovine (Methergine)
- Prostaglandins
- Hemabate
- Dinaprostone (Prostin E2)
- Misoprostol (Cytotec)
How to give oxytocin with PPH
Danger with infusions ?
20 units/Liter
- Avoid IV push~ causes vasodilation
- Fluid Overload is a potential danger with Oxytocin infusions.
How to give Methylergonovine (Methergine)
How often?
Med type?
What patients to avoid?
- 0.2 mg IM
- Q 2-4 hours
- Vasoconstrictor
- Avoid with hypertensive patients and any cardiac history
- Avoid with Asthmatic patients
Hemabate with PPH
How to give
Patients to avoid?
May cause what?
Q 15-90min IM: 0.25mg
- 8 doses max
- Cause significant GI issues: Consider using Lomotil
- Avoid with asthmatics, patients with hepatic, renal or cardiac diseases
PPH:
Misoprostol (Cytotec)
How to give?
- Causes the uterus to do what?
- Do NOT handle cytotec when?
600-1000 micrograms rectally x 1
- Causes the uterus to contract and expel any remaining fragments/blood
- Do NOT handle cytotec if you are pregnant or trying to get pregnant.
silicone, obstetrical balloon specifically designed to treat postpartum hemorrhage (PPH).
The device is used for the “temporary control or reduction of postpartum hemorrhage when conservative management of uterine bleeding is warranted.
Bakri balloon
Know lacerations after birth
1-4th degree
1- slight tear
2-superficial - stop before hitting anus
3- hit top of anal sphincter-external
4 -hit internal anal sphincter and rectal mucosa
Hypertensive disorders in pregnancy
Chronic Hypertension (of any cause)
- Gestational Hypertension or PIH
- Preeclampsia superimposed on Chronic Hypertension
- Preeclampsia-Eclampsia
Labetalol (Trandate)
Type of med
Does what?
Contraindicationed in who?
Side effects?
- Beta Blocker
- Decreased BP without decreasing maternal heart rate or cardiac output
- Crosses placenta
- Side effects: Hypotension, Dizziness, N/V, Bradycardia (maternal and fetal)
- *****Contraindicated in women with asthma or hypoglycemia
Hydralazine (Apresoline)
Used for ?
Precautions?
When to repeat dose?
Side effects?
- Most widely used agent for acute hypertension
- Extremely safe
- Do not allow pressure to fall below 90 to prevent further blood flow to placenta and fetus.
- Dose can be repeated every time diastolic pressure reaches 110mmHg
- Side effects: Tachycardia, dizziness, faintness, headache, palpitations, numbness, or disorientation. Fetal effects are low heart rate and low Apgar at 1 minute.
- Contraindicated in patients with hypertension and tachycardia.
Seizure in pregnancy associated with pre-eclampsia
- May occur up to ? hours after delivery
- nursing interventions?
Medications? Route ?
eclampsia
- May occur up to 48 hours after delivery
- Protect airway – patient on side, O2
- Get help
- Mg sulfate 6gm IV bolus
- If has Mg running give 2 gm bolus
- If no IV 5g IM in each buttock for 10g total
- Benzodiazepines
How Long seizures and bradycardia typically last in eclampsia
Seizures seldom last more than 3-4 minutes (usual duration 60-75 seconds)
Fetal Bradycardia lasting 3-5 minutes is a common finding during and immediately after eclampsia
Eclampsia management
And documentation?
Prevent injury
- Avoid pushing drugs through direct venous access
- Do put anything in the mouth
- Maintain oxygenation
- Minimize aspiration
•Pharmacologic agents
Valium is no longer the first line agent to stop seizure activity, depresses fetus and decreases maternal gag reflex
•Maternal and Fetal Status
uterine hyperstimulation and fetal bradycardia are common responses in postictal state
•Document time of onset, associated symptoms, and duration of seizure
Drug used to prevent seizures in preeclampsia
•Acts as a CNS depressant and smooth muscle depressant
•Prevents or lessens seizures by elevating seizure threshold
•Dilates vessels and increases cerebral perfusion
•Blood pressure will decrease initially due to vasodilatation, but decrease does not continue with prolonged infusion (may need anti-hypertensive medications also)
- ***High Risk Medication
- Double Check
- Must be on its own IV pump and not hung as secondary
Anticonvulsant
Magnesium sulfate
Postpartum family education
Both mother and the family support system needs to have information about normal and abnormal mood changes.
•Rest and good nutrition can help most mothers overcome the normal psychological adjustments.
Depression during pregnancy
What might it lead to?
Assessment may be difficult in pregnancy because symptoms of pregnancy may mimic depression
•If untreated, may lead to Postpartum Depression
Postpartum
Psychological Disorders
- Baby Blues
- Postpartum depression
- Postpartum psychosis
- Anxiety Disorders
- Panic Disorder
Typically begins Postpartum Day 3 and can last 2-3 days
•symptoms subside by the second week.
•Coincidences with the normal physiologic drop in estrogen, progesterone and prolactin levels.
•Occurrence is 3-50% of women
Postpartum baby blues
Postpartum Baby Blues:
Symptoms
- Inability to cope
- Fatigue
- Anxiety
- Irritability
- Tearfulness
- Insomnia
- Weepiness
- Headaches
- Poor Concentration
- Affective lability
Symptoms include: agitation, confusion, insomnia, delusions, hallucinations, and rapid mood swings
•5% of women may commit suicide and
2-4% may harm the infant
•is a Psychiatric Emergency
-Incidence 1-2 per cases per 1000 births
Postpartum psychosis
Postpartum psychosis nursing interventions
- Recognize the signs and symptoms and realize these women may be experiencing feelings of guilt or shame
- Women may find it difficult to share these feelings with the nurse or provider but the nurse should encourage the mother to share any negative emotions she may be experiencing
- Include support person(s) in DC teaching
Maternal Depression:
Effects on Infant Behaviors
Fussier •More avoidant •Fewer positive facial expressions •Fewer positive vocalizations •Early unplanned weaning
is the phrase used to describe the time in a baby’s life when they cry more than any other time.
begins at about ? weeks of age and continues until about ? months of age?
During this phase of a baby’s life they can cry for hours and still be healthy and normal.
State mandated to do what?
The Period of PURPLE Crying
2 weeks until 3-4 months
Educate families about this
How to smooth a purple crying infant
Feed your baby.
Hunger is the main reason a baby will cry.
Burp your baby.
Give your baby a lukewarm bath. …
Massage your baby. …
Make eye contact with your baby and smile.
Kiss your baby.
Sing Softly.
Hum in a low tone against your baby’s head.
How much is total volume of lochia ?
About 225ml
Varies by 150-400mL
What time of day is one expected to have the most lochia
Greater in the morning because of pooling
What women have more lochia
What women have less?
More- multipara women , vaginal births
Less- first time moms, c-section births
Following delivery the cervix looks how?
External Os look?
Internal Os? Closes when?
Edema and bruised
Slit vs dimple prior to birth
Closes by 2 weeks following delivery
The vagina after birth
Will never return to the pre-pregnant size
Dryness and pain due to decreased estrogen levels
Encourage water based lubricants to ease pain
Mucous production returns with ovulation
Vulva after birth
May appear bruised early in the puerperium due to pelvic congestion which goes away after delivery
Gradually regains tone of the pelvic floor in the first 6 weeks due to decreased estrogen
Perineum after birth?
Skin stretches and thins
Lacerations and episiotomies
Swelling
Physiology of the breast after birth
- what stimulates milk glands
- hormone responsible for milk let down
- Separation of placenta from uterine wall creates a drop in progress strong levels and increase in estrogen
What else ? Size/color?
Prolactin - stimulates milk glands
Oxytocin
Lactogensis 2
Increase in size
Darkened areola
How to asses breasts after birth
Condition of breasts and nipples
Comfort/cream, gels?
Assess infant latch
How common is urinary incontinence during and after birth?
S/s?
do they resolve?
30-60% of women During
6-35% after
S/s- mild Leakage
The issues resolved in the postpartum period In 70% of those affected
How to resolve urinary incontinence
Kegels- contracting your pelvic floor muscles like your peeing and stopping it mid flow. Repeat 10x
Work up to keeping muscles contracted for 10 seconds at a time
GI system after pregnancy
Hungry and thirsty after delivery due to energy used during labor
Diaphoresis leads to thirst
What to do before giving food and drink after birthing
Evaluation of postpartum status
Rubella vaccination - what to educate
Prevents fetal anomalies
Pregnancy prevention should occur 4 weeks following vaccine
RH factor
Transfer of RBC occurs when there is a defect or break in the placental membrane
This is the cause of what
RH sensitization
RH factor
Antibodies develop leading to possible harm to future pregnancies with?
RH positive infants
RHogam given for who
Prevents ?
When tonadminister?
Rh negative mother/Rh positive baby
Prevents sensitization of mother
Administer after each delivery and after uterine injury and/or tests such as miscarriage Or amniocentesis
Postpartum hemorrhage
s/s?
Who it affects?
How much blood is considered PPH? Vaginally and c-section?
Decrease in what lab ?
How common?
Hemodynamic instability - light headed, tachycardia, hypotension
500ml- vaginally
1000ml C-section
10% decrease in hemacrit
Vaginal- 4%
C-section- 6%
Ways to clear retained placenta following delivery
Manually
Sharp curettage
PPH general management
BLEEDING
B- Blood loss needs L-loss estimation E-etiology, uterine, laceration, hematoma E- EBL replacement D- drug therapy I-intraoperative N- non-obstetrical G- general complication assessment
PPH and fluid and blood replacement
How much fluid and what kind?
Additional Blood replacement depends on?
And?
3:1 blood loss replacement with lactated ringers or normal saline - 3mL for every 1mL of blood loss to maintain cardiac output
Depends on pt status and health hx
Oxygen administration
Emergency blood type administration?
O negative
I and o measurement is indication of what?
Adequate organ perfusion and oxygenation
Cathedar is invasive or non ?
Non invasive
How does aldosterone and angiotensin assist circulatory blood volume
Conserves fluid volume
Why might the uterus fail to contract or remain firm during involution?
Placental separation after delivery exposes large uterine blood vessels which are normally closed off the uterine contractions
What to do if ones uterus fails to contract
Fundal massage
Oxytocin admin
Natural oxytocic substances release during breast feeding help stimulate contractions
First line tx for post partum hemorrhage
Given when
Oxytocin
After delivery to prevent uterine atony
What to monitor with oxytocin
High alert med - what is required ?
Complications?
Document what?
I&O
Independent double check to verify patients identity and med correction/dose/route/pump settings
Can cause anaphylactic reaction, cardiac arrhythmia, hypertensive episodes, nausea, vomiting, hemorrhage, uterine rupture
Document the response to oxytocin, blood pressure, pulse rate and pattern, respiratory rate—
Document rate, input and output, effect on uterine atony and postpartum hemorrhage. Document that teaching was performed in that patient comprehends your teaching
Women me excrete up to how many milliliters of blood per day after 12 hours postpartum?
What should they be educated on?
3000 mL
They should be educated about sweating, increased urination, and perspiration during this period
Bladder tone after delivery
Diminished tone resulting in inability to feel the need to urinate
What does a full bladder due to the uterus
What to do after delivery?
A full bladder displaces The uterus upwards and laterally to the right and
prevents contraction of the uterus
This causes uterine atony which increases risk of PPH
Healing of perineum occurs within when?
The first two weeks but it may take up to 4 to 6 months to completely heal
What does the type and amount of Lochia after birth determine
Infection, normal uterine involution, the stage of healing of the placenta site.
and progressive change from bright red at birth to dark red to pink white or clear should occur
How does the placenta site heal?
By the process of exfoliation
Immediately after birth of placenta , then uterus contracts to the size of a
During pregnancy the uterus is increased how many times it’s non-pregnant size
WT of non pregnant uterine
large grapefruit
11x
2oz
PPH hematoma s/s
Increased pelvic pain and or rectal pressure
Reddish blue mass visualized
Tx of PPH hematoma
Contact provider Monitor Inspection Increase IV fluid rate Record vitals Evaluate color Type and amount of blood loss
