Quiz 3 Flashcards
4th Stage of Labor
Immediate Recovery Period Postpardum - 4-6 hours post delivery with frequent vitals and fundal exams
Oxytocin in postpardum
Released by posterior pituitary - leads to afterpains that constrict the vessels at placental separation
Placenta attachment area
3-4 inches in diameter, heals via exfoliation and without a scar
Autolysis
The self digestion that occurs in tissues or cells by its own enzymes - r/t withdrawls of estrogen and progesterone
Lochia - Postpardum period
Measured in scant, light, moderate or heavy
Rubra (Day 1-3)
Serosa (Day 4-10)
Alba (Day 10-3 wks)
Dark red to muscousy discharge colored
Cervix Postpartum
Healing from trauma - internally closes in a few days (takes 6 weeks to completely heal)
Edematous, bruised, ragged appearance with small soft tears
Vagina postpartum
Thin, rugae absent (expanding lines) dry (muscous increases with the return of estrogen production)
Perineum Postpartum
Edema, brusing, altered muscle tone (r/t movement)
Episiotomy healing - absorbable sutures used
Returns to per-birth in 6-8 weeks
Laceration Degrees
1st degree: skin and superficial tissue
2nd degree: Through muscles of perineum
3rd degree: Through sphincter muscle
4th degree: involved the anterior rectal wall
Laceration nursing considerations
Stool softeners, ice, squirt bottles, wipes, sitz baths and kegal exercises
Hormones postpartum
Breastfeeding mimics menopause states
Placenta delivery reverses diabetogenic effect of moms with gestational diabetes (lowers blood sugars)
Estrogen and Progesterone - leads to breast engorgement, diuresis and HCG is gone by day 14
Pituitary effects if breastfeeding
Elevated prolactin, suppresses ovulation (may around 6 months)
Pituitary - Not breastfeeding
Prolactin levels decline, ovulation is as early as 27 days, most menstruate within 3 months
Urinary system postpartum
Delayed, altered voiding relfexes
Interventions: encourage voiding even if they don’t feel it
Gi postpardum
Constipation, reluctance (r/t pain) timing can be difficult
Postpartum circulatory changes
EBL: ~1000 for Cesarean
Hypercoagulability - more platelets in early postpartum because of vessel damage, and immobility
Increased WBCS r/t stress of delivery
Postpartum assessment (BUBBLE)
Breasts
Uterus
Bowels
Bladder
Lochia
Episiotomy/laceration/C-section Incision
RH factor
Uterine Atony
Hypotonia of the uterus (decreased muscle tone, does not contract)
Risks: Traumatic birth, rapid or prolonged labor, induction, hydramnios, macrocosmic fetus, multifetal
Postpartum hemorrhage (PPH)
EBL of >500mL or
10% change in hematocrit
Pt needs RBC infusion
Early/Acute/Primary - within 24 hours of birth
Late/Secondary - More than 24 hours but less than 6 wks
Medical Treatment for Uterine Atony
Pitocin, methergine, Hemabate, Cytotec, Dinopro
Surgical management of uterine atony
Balloons, packing, foley catheter, artery litigation, hysterectomy, JADA device
Hematoma formation postpartum
Vulvar (most common) Vaginal or retroperitoneal
Pain is most common symptom
Retained Placenta
Complete or partial retaining of placental (after 30 minutes)
Treatment is manual removal
Placenta Accreta
slight penetration of the myometrium by the placenta
Adherent retained placenta (1)
Placenta Increta
deep penetration of the myometrium by the placenta
Adherent retained placenta (2)
Placenta percreta
Uterus is perforated by the placenta
Adherent retain placenta (3)
Treatment of Adherent retained placenta
Blood replacement and hysterectomy, placenta is retained too deep, will continue to bleed
Inversion of the uterus
Complete: red mass protrudes 20-30 cm out of the introitus (vagina)
Incomplete: palpated smooth mass that comes through dilated cervix
Can be life threatening
Factors: Fundal implantation, uterine atomy, excessive cord traction, adherent placenta tissue
Subinvolution of Uterus
Late pp bleeding r/t retained placenta fragments, pelvic infection
SS: prolonged lochial discharge, irregular or excessive bleeding, hemorrhage, larger than normal uterus + boggy
Treat cause - may include remove fragments and treat with antibiotics
Hypovolemic shock
Emergency, vessels constrict so the blood goes to vital organs, cell death occurs, lactic acid and acidosis increases
Management: Restore blood volume (fluids and replacement) Treat cause of hemorrhage
Hypovolemic shock interventions
Signs may not appear until 30-40% of volume has been lost, improve/monitor perfusion, take vitals, watch I/O
DIC
Form of clotting where all the clotting factors are consumed leads to widespread bleeding
SS: Unusual bleeding from IV site, venipuncture sites or petechia under BP cuff
DIC management
Treat underlying cause (arrest, hemorrhage, preeclampsia, sepsis)
Replace volume, replace blood, apply oxygen, monitor labs and perfusion + IO
Thromboembolic Disease
Formation of clot in vessel but inflammation
Risk: hypercoagulation, venous statis, obesity, smoking
Increasing ambulation decreases risk
Thromboembolism Superficial
Pain and tenderness in lower extremities with warmth, redness and enlarged vein over the site
Deep thromboembolism
More common in pregnancy, unilateral leg pain, calf tenderness, swelling, redness and warmth, positive homans (flex knee and ankle causes pain in leg)
PP Infection risk
Prolonged labor, c section, internal monitoring, diabetes, immunosuppression
Endometritis
Most common PP infection - begins as localized infection at placenta site
SS: fever, chills, pelvic pain, foul smelling discharge
Mastitis
Unilateral, after flow of milk has been established, edema obstructs flow, can progress into an abscess, most common staph aureus
SS: chills, fever, malaise, local tenderness, pain, swelling, redness
Treatment: antibotics and frequent emptying
Best way to prevent infections
Hand hygiene
Physiologic Adjustment of the NB
Establish and maintain respirations, circulatory changes, regulating temperature, ingesting retaining and digesting nutrients, eliminating waste and regulating weight
Breathing, Temp, Nutrients, Waste and Weight
NB Behavioral Adaptation Tasks
Pattern of sleep, regulating arousal, processing storing and organizing stimuli and relationship with providers
Transition period for NB
First 6-8 hours
What does clamping the cord do?
Increase the baby BP, increased circulation and lung perfusion
Chemical stimulation of respiratory
Decreases prostaglandin, causes fetal hypoxia
Contractions lead to decreased Po2, increased PCO2 and a lowered pH
Planned C-Section babies at risk because they did not get this benefit
Mechanical Respiratory stimulation
Intrathoracic pressure when the fetus is going through the uterus
Thermal Factors stimulating respiration
Extrauterine environment is colder (72 standard) than the uterus, the skin
Sensory Factors stimulating respiration
handling of baby, suctioning (mouth then nose or will aspirate) drying, pain, lights/sounds/smells
Surfactant
Alveoli are lined with this and the lung expansion at birth releases it.
The surfactant reduces the pressure required to keep the alveoli open
Respiratory Vitals in NB
30-60 per minute with pauses of 15 seconds normal
If pause is >20 it is apnea and that is problematic
Signs of respiratory distress
Nasal flaring, retractions, grunting, seesaw respirations, pallor, central cyanosis
Cardiovascular NB adaptations
Increased pulmonary blood flow will close the foramen ovule over time can lead to a transient (come/go) murmur
Immediate closure of the ductus arteriosus and ductus venosos
Normal NB HR
100-160
Crying or deep sleep can alter values, count for a full minute at the fourth intercostal space and to the left of the midclavicular line
Signs of CV dysfunction, what should you do?
tachypnea, tachycardia, pallor, cyanosis, absence of peripheral pulses, poor perfusion
Do: Obtain 4 pt blood pressures - if the MAP is below the gestational age it is hypotensive
Hypertensive is a MAP between 50-70
Blood volume of NB
85 ml/kg at birth 300 ml (if delayed clamping extra 100 ml)
Late clamping increases HR, increases systolic, increases respirations
Pathologic jaundice
Occurs before 24 hours related to availability of RBCS or RH issues
Abnormal destruction of RBC’s leads to jaundice
Signs of NB sepsis
Low temp, decreased WBCS, pallor
Thermoregulation in NB
maintaining balance - not losing heat or producing heat
97.8-98.8 use clinical judgement for higher temps
At risk for loss r/t less adipose tissue, vessels close to skin, large surface area to body weight
Convection - Heat loss
Losing heat to cooler air
Radiation - heat loss
Loss of heat due to cooler surface that is not in direct contact
Evaporation - heat loss
Losing heat turning liquid to vapor (sweating)
Conduction - Heat loss
Loss of heat bc of contact with a cooler surface
NB thermogenesis
Generating heat by increasing muscle activity, crying/restless
Brown fat
Unique to NB, richer vascular and nerve supply that increases heat production, located over important organs
NB cold stress
Respirations increase, burning glucose in the blood, increases risk of acidosis and hyperbilirubinemia
Hyperthermia
Skin vessels dilate, flushed skin, warm to touch, extension of limbs
Septic hyperthermia: constricted, pale, hands/feet cold
Red Brick Staining
uric acid crystals in urine that can look like blood
When should babies first void
Most void within 30 hours if not before 48 consider renal impairment
Daily fluid requirements
First 2 days: 40-60 mL/kg
Then: 100-150 ml/kg
75% of body weight is water
40% of body weight is extracellular
Loss of fluid after birth
Baby should lose 5-10% of birth weight in the first 3-5 days then regain that by day 14
Epstein perals
White cysts present in the gums of NB, retention cysts
Stomach capasity of NB
30-90 ml, avoid over feeding
When should baby pass meconium what is it composed of
Within 24 hours of life has amitotic fluid, intestinal secretions and cells
Blood sugar of NB and signs of hypoglycemia
40-80
Jitters, tremors, irregular RR, difficulty feeding, lethargy, apnea, cyanosis
Bilirubin
Yellow pigment that comes from the break down of RBCs and breakdown of myoglobin in muscle cells
Jaundice (Physio and Pathologic)
Hyperbilirubinemia
Vernix caseosa
White stuff covering baby to keep skin safe in utero
Acrocyanosis
Blue hands/feet pink body
Mongolian spots
Spots on the back of baby, harmless, need to be noted at birth or could be seen as abuse later
Caput succadanem
edematous swelling that crosses suture lines, disappears in 3-4 days common with vaccum extraction`
cephalhematoma
collection of blood between skull bone and periosteum that does not cross the suture line
NB vision
React to light, track objects, 12 inches of vision and prefer patterns
Pain in neonate
Increased RR and HR, shallow respirations, pallor, dilated pupils, grimacing ,eye squeezing, quivering of tongue, open mouth
Maternal adjustment - taking in
self focus, relies on other for needs, exited, relives the birth experience
Taking hold - maternal adjustment
focus on baby, taking charge, eager to learn and practice, still needs help from others
Letting go = maternal adjustment
forward as fmaily unit, resuming individual roles, resuming relationship with partner including sexual intimacy
Breast feeding contraindications
HIV, TB, HSV on breasts, galactosemia in NB, humal t-cell, chemo in mom and radioactive isotopes
mL for babies
20-40 mL/kg (until day 2)
100-140 mL/kg
protein values needed for nb
2.25-4g/kg/day
fat values needed for nb
5-7g/kg
15% of calories must come from fat
corn oil is fat in formula
what produces the milk in breasts
alveoli
what are the alveoli surrounded by
myoepithelial cells - that contact the milk and send it inot the ductules
purpose of the ductule
collects the milk, becomes larger ducts where the milk collects behind the nipple
