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Maternal health > T2: Intrapartum Pain/Pospartum Changes/Complications/Neonatal Assess/Nursing Care > Flashcards

T2: Intrapartum Pain/Pospartum Changes/Complications/Neonatal Assess/Nursing Care Flashcards

1
Q

What is puerperium?

A

The 6 week period after birth during which the woman’s body returns mostly to its pre-pregnant state.

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2
Q

What affects the fundal height and involution?

A
  • The size of the baby.
  • How many pregnancies/deliveries she’s had
  • How much subcutaneous tissue pt has
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3
Q

At delivery the fundal height should be 1 finger width above the umbilicus… Day 1 after birth it should be at the umbilicus… every subsequent day it should be how far down?

A

1 finger width below the last day’s position.

At day 10 it should no longer be palpable (becoming an inside-pelvis-organ).

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4
Q

When assessing the tone and position of the uterus (after the patient has voided) what should we think about it it is soft? firm with bleeding?

A

After massage, if the uterus continues to be soft then think retained placenta.

If it is firm with continued bleeding, think laceration. Either vaginal or cervix.

If uterus is displaced to the RT side, can be a full bladder.

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5
Q

What is the name of the blood and desidua that is discharged after birth?

A

Lochia. Superficial layer sloughing off.

  • Rubra is the first 3 days. Deep red small clots.
  • Serosa is 4-10 days after. Pinkish brown.
  • Alba are days 10 days to 6 weeks. Creamy white-light brown.

At first like heavy menstrual period 1-3 days.

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6
Q

Word to describe less than 1 inch stain on pad:

1-4 inch stain:

4-6 inch stain:

Saturated in one hour:

A

Scant.

Light.

Moderate.

Large.

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7
Q

Factors that promote involution:

A
  • Expulsion of the amniotic membranes and the placenta at birth.
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8
Q

Physiological changes at perineum:

A

Slight edema in Vagina.
May have laceration sutures and/or bruising.
Place of placenta healing wound for 6 weeks.
Cervix is not the same after, more spongy and slightly open.

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9
Q

Nursing care for perineum:

A

Assess infection/bruising/hematoma/suture approximation/type of lochia, hemorroids/uteran atony… we’re going to weigh the pads if we are concerned (1gm=1mL).
Hand washing…
New pad each void.
Peri-bottle with warm water, pat dry.
Comfort measures. - Ice pack first 24 hours.
Sitz baths 3 x a day as needed to promote circulation and healing. Tucks and Dermoplast are cooling and numbing.

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10
Q

What are the physiological changes with the GI system?

A

Decreased motility several days after birth.

Could also be related to analgesics, surgery, less abdominal pressure, decreased intake, decreased muscle tone (can lead to constipation and gas).

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11
Q

Physiological changes in the urinary system:

A

Retention, related to tone, elasticity and sensation.

Diuresis: as body normalizes fluid volume, first 12-24 hours have large amt of fluid to release due to IV, oxytocin (causes you to retain fluid), woman’s decreasing aldosterone level decreases her retention of Sodium.

Retention increases the risk for uteran atony… which increases risk of hemorrhage… so need to make sure they’re voiding.

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12
Q

Nursing care for GI:

A

Avoid constipation

Promote fluids, fiber, ambulation

Stool softeners as needed.

Fear of BM (pain, stitches, etc.)

Nutrition: diet as tolerated. Calories are same as pregnant when breastfeeding.

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13
Q

Nursing care for urinary:

A
  • Accurate I and O until they’ve voided twice.

*If trouble with voiding:
Peppermint oil, warm water with peri bottle, ambulating, relaxation, running water

  • Kegel exercises. 50% of parus women have stress incontinence with pelvic prolapse during their lifetime. Need to teach it strengthens the pelvic floor muscles and prevents incontinence. As tolerated and then increase.

S and S of retention:
Fundus shift to RT
Cath if needed

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14
Q

Physiological changes with Lab Values:

A

Postpartum clotting factors remain elevated 2-3 weeks

WBC elevate during birth and 4-6 days

Decrease blood volume and normalizes to pre pregnant state in 4 weeks.

Circulatory: increase clotting factors and relaxation of smooth muscle leads to stasis of blood which increases risk for DVT’s.

VS: BP stay at baseline. HTN is still risk up to 6 weeks postpartum. HR bradycardic first 6-10 days due to less cardiac strain. Temp is elevated slightly in first 24 and when milk comes in around day 3.

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15
Q

General Nursing Care:

A

Circulatory:
Homan’s sign: Knee slightly flexed, firmly and abruptly dorsiflex the ankle. Pain may indicate positive Homan’s sign which may indicate a clot.
Redness, warmth, tenderness, pulses bilaterally.

VS:
Frequent due to risk for hemorrhage and fluid shifts
Complications: Shock, dehydration, preeclampsia, infection. Although, VS are a late sign of blood loss.

Orthostatic blood pressures with any anesthesia’s (epidural/spinal).

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16
Q

Musculoskeletal changes:

A
  • Diastasis recti abdominis are often separated during pregnancy to accomodate uterus… some may go back together again, some may not.

Relaxin is the hormone that loosens the joints during preg. May experience affects that remain postpartum.

Supportive pelvic floor is stretched out and may take months to repair.

Uterus needs to involute through contractions.

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17
Q

More nursing care of postpartum woman:

A

Pain management (rest and meds)

Ambulation DVTs and helps with soreness

Exercises kegel, limit strenuous for 6 wks

Cluster care to allow for rest and bonding

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18
Q

Changes to the endocrine, ovarian, menstruation, and breasts:

A

endocrine: rapid decrease in hormones
ovulation: 2-4 weeks not breast feeding, 6 months if breastfeeding. Ovulation occurs BEFORE menstruation… so can still get pregnant even if not getting a period.
menstruation: begins 7-9 weeks not breastfeeding, 4 months to weaning if breastfeeding (varies greatly).

Breasts: increased blood flow, connective tissue, fat, adn fluid combine = engorgement. Prolactin and oxytocin stimulate these changes.

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19
Q

What is the name of the hormone that triggers the let down of milk?

Which hormone triggers the production of milk?

A

Let down by oxytocin

Milk production by prolactin

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20
Q

Nursing care for breasts:

A
  • Education about the hormone changes, ovulation, menstruation
  • Breast care:
    Nipples - type (everted/flat/inverted) - breastfeeding pain?

Engorgement 3-5 days postpartum from lactogenesis II, mature milk is coming in. Can use ice packs in between feedings, and warm compress right before feeding.

Takes 5-7 days for milk to “dry up.” Wear supportive bra, use ice packs, and limit stimulation.

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21
Q

What is the American Academy of Pediatrics recommending for breastfeeding?

World Health Organization recommends:

A

Exclusively for the first 6 months. Then continuing to at least 1 year.

WHO same except continue until 2 years.

We need to educate about the health benefits for the baby but also for the mother.

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22
Q

When is colostrum first developed?

A

16 weeks gestation.

What baby gets day 1-3.

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23
Q

Need a minimum of 8 feedings in a 24 hour period

A

to keep milk production.

more frequent = more milk

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24
Q

How are breastfed babies measured for adequate intake?

A

Satiety and output.

Frequency is more important than duration.

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25
Q

Nursing care of newborn:

A
  • Emotional support
  • Encourage attachment behaviors (eye contact, calling baby by name, holding, etc.)
  • Who will be helping the new parents at home?
  • Include support person in all education also keep culture in mind while teaching
  • Anticipatory guidance: tension, fatigue, ambivalence
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26
Q

Maternal Role Theory’s 3 stages:

A
  1. Taking-In Phase - days 1-3: needs must be met before she can tend to the baby, she tends to be passive and talkative of her birth experience.
  2. Days 3-10: Taking-Hold Phase: wants to control her needs, independence and autonomy, very present focused. Best time for education.
  3. Letting-Go Phase: days 10-14: Support needs, gaining confidence. Encourage them to vocalize their feelings, it’s all normal and ok.
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27
Q

Partner Role Adaptation Theory:

A
  1. Expectation: what life will be like, they are not as aware as the dramatic changes… then
  2. Reality sets in with sadness/frustration.
  3. Transition to Mastery: make decisions, take control and get involved regardless of how unprepared they feel.
28
Q

Care Plan for postpartum woman:

A
  • Assist in restoration of physiological and psychological status
  • Assist in learning and adjusting to new roles
  • Support parent-child attachment.
29
Q

Discharge Instructions:

A

Mom if c-section at 2 wks and 6 wks
vaginal 6 wks

Baby: lactation follow up in first 3 days of life

30
Q

When should they call their provider?

A
  1. Signs of Infection
  2. Change in lochia
  3. Breast pain
  4. DVT S/S
  5. UTI S/S
  6. PP Depression
31
Q

How long is true postpartum period?

A

9-12 months as physiological and psychological changes occur.

32
Q

What is the difference between analgesia and anesthesia?

A

Analgesia is to reduce the pain.

Anesthesia is to block the pain.

33
Q

What are some down sides to medication during labor and delivery?

A
  • May stall out labor

- May affect the baby.

34
Q

Why is it important to care for pain?

What other ways are we able to care for pain?

A
  • Uncontrolled pain leads to vasoconstriction!
  • We can relieve pain w/out interfering w/the labor process.
  • Nonpharmacalogical support is given with or without pharmacological support.
35
Q

Why do we administer anti-emetics with opioids?

A

The anti-emetic decrease anxiety and increase sedative affect.

Benzodiazepines also potentiate opioids but are used primarily in emergencies and operating room. We don’t want to use them unless we have to bc they all cross the placenta.

Avoid giving 1-2 hours within delivery!!! Otherwise will sedate neonate and interfere with their ability to thrive.

36
Q

Why is Fentanyl drug of choice around here?

A

It has a short half life and felt w/in 15 minutes.

Morphine has longer 1/2 life.

We give it during peak of contraction to decrease risk of side effect to baby bc decrease circulation during contraction.

37
Q

What does ovulation depend on?

A

When the pituitary function returns.

Why did the pituitary function cease?

38
Q

Dermatome goal for epidural:

A

T8 through T10 blocked.

We check block 5 ways:

  1. Pain
  2. Sensation
  3. Motor Function
  4. Respiratory Rate
  5. LOC
39
Q

When is local infiltration used?

A

In repair or anticipatory for epesiotomy.

40
Q

3 types of neuraxial anaglesia/anesthesia:

A
  1. Epidural
  2. Spinal
  3. CSE: Combined Spinal Epidural

These are local nerve blocks.

Advantages:
mom participates
relatively low side effects.
meds available as long as needed.

Disadvantages: 
maternal hypotension
dyspnea
can lengthen labor if given too soon
post-dural headache (from pressure due to change of CSF - rare)
41
Q

What are the 3 parameters that need to be met in order to receive an epidural?

A
  1. Need to be stable
  2. Given at least 500 mLs of fluid via IV
  3. Labs come back clear (risk for bleeding)
42
Q

What are some things that labor support can prevent?

A

Can decrease risk for assisted/operative delivery.

Ex: C-sec, vacuum, forceps

43
Q

What L #’s is the epidural placed in?

A

Between L3 and L4

Placed in “potential” space… since not directly in spinal, given a higher dose.

44
Q

What are the contraindications for an epidural/spinal?

A

Patient is not stable.

Spinal deformity.

Previous back surgery.

Obese: makes placement very difficult.

Last - Pt has a bleeding disorder or is on an anti-platelet.

45
Q

What is the difference between an epidural and a spinal?

A

Spinals are direct injections into the spinal fluid in the subarachnoid space.

They are used for C-sections, unless pt already has an epidural, they will just use that.

It’s one dose.

Duramorph is a preservative-free morphine with a 24 hour 1/2 life!!! Be thinking about its side effects.

46
Q

What is “regional anesthesia?”

A

One form is a CSE: combined spinal epidural.

For labor they are given the one strong dose (spinal) which kicks in w/in 5 minutes and lasts about 2 hours. Once it metabolizes out, the epidural is still there to pick up the slack.

Biggest risk:
Lower BP
Respiratory depression
Prolonged labor

Benefit:
Much less risk for baby (than opioids) bc it’s local not systemic.

47
Q

When would we use general anesthesia for childbirth?

A
  • For emergencies only.

If the baby is in distress, you only have 9 minutes to get that baby out with minimal side effects (brain damage/death).

  • We apply cricoid pressure to the pts cricoid cartilage until they are successfully intubated… very uncomfortable…
  • Risks:
    Aspiration from vomitting
    Systemic side effects. These affect the baby and its ability to thrive upon deliver (resp.depression) so it is done FAST. Knock out mom and cut her almost simultaneously to decrease neonate risk from anesthesia.
Other risks from the drug/procedure - 
respiratory depression
pneumonia
hypotension
asphyxiation
increased risk for hemorrhage due to vasodilation of drug.
48
Q

Nursing considerations:

A

Monitor!

    • Safety (fall risk: can’t get out of bed w/epidural)
    • VS every 5 min for the first hour and until stable
    • LOC
    • Dermatomes
    • Fetal status
49
Q

Require knowledge of:

A
  • Side effects of involved medications (and their 1/2 lives)
  • Complications that may develop
  • Emergency equipment that may be used.
  • Policies of the facility. (Ex: we can’t change dose of an epidural but we can stop them in emergencies and we can also rehang bags with another nurse).
50
Q

What are some ways we as the nurse can provide labor support?

A

Providing non-pharmacalogical support for pain relief.

Being their advocate.

Being there for them, with our presence.

Coaching them, encouraging them.

51
Q

What are the numbers we need to be concerned with regarding bilirubin?

A

Over 18 - 20.

Can cause kernicterus.

52
Q

What is kernicterus?

A

Cerebral damage

53
Q

Normal pulse rate for neonate:

A

120-160

54
Q

Normal BP for neonate:

A

60-80 over 40-45

55
Q

still need to do post partum complications, neonatal assessment…

A

nursing care of the neonate and any handouts.

56
Q

Reasons for uterine atony:

A
  • Over distended uterus
  • Prolonged or rapid labor (muscle fatigue)
  • C-section delivery
  • Anesthesia
  • Preecclampsia
  • Muiltiparity
  • Prolonged use of Pitocin, Mag sulfate, betamethasone

(subtle signs - don’t depend on VS late sign)

57
Q

3 levels of caring for a soft uterus:

A
  1. Massage. Have patient concentrate on their breathing.
  2. Physician may have to come and perform intrauterine massage if external does not help.
  3. If uterus continues to not respond the pt may have to undergo a hysterectomy.
58
Q

What does APGAR stand for?

A

A - Appearance: color blue/pale to completely pink

P - Pulse: absent to above 100

G - Grimace: no response to cry

A - Attitude (muscle tone): limp to moving

R - Respiration: absent to good, strong cry

Test given at 1 min and 5 min after birth.
0 - 3 = needs resuscitation
4 - 7 = needs stimulation
8 - 10 = excellent

59
Q

After airway, what’s the greatest concern for newborns?

A

Hypothermia.

Optimal temp is 97.7 - 98.6 F

60
Q

Thermoregulation/Methods of heat loss:

A

Wet: Evaporation

Transfer of heat to the air: Convection

Radiation

Heat loss through contact: Conduction

Baby will be placed in radiant warmer if temp goes down to 97 F, first attempt is skin to skin.

61
Q

What is the transition period for newborns?

A

The first 2 hours after birth.

Usually kept in transition until:

  • 1 feeding without difficulty
  • Stable temperature
  • Blood sugar at 45 or above
  • Current practice is to delay bath for 24 hours
62
Q

Care during transition:

A
  • Wear gloves until they’ve had a bath and during every diaper change
  • BP is done only if there is a murmur or indicated by condition
  • VS ever 15 min, then every shift
  • Axillary temp
  • Apical pulse for 1 full minute (120-160)
  • Respirations: listen/feel for 1 full minute (30-60)
  • Use NPASS to score pain
  • Measurements and assessments
  • Assist mom with breastfeeding within 1 hour of birth
63
Q

What two cares are state law but the parents can refuse?

A

1) Ilotycin oitment (or silver nitrate [can cause black tears]) to prevent opthalmia neonatorum.
2) Vit K (aquamephyton) to prevent bleeding weeks 6 - 15.

64
Q

Benefits of breastfeeding:

A
  • For mom: stimulates a quicker involution of the uterus and decrease bleeding/risk of hemorrhage, and gives her a sense of fulfillment.
  • For baby: immune factors from mom, less respiratory infections, less GI upset.
  • Safe, fresh, readily available (don’t have to heat it up)
  • Easiest for baby to digest.
  • Less expensive
  • Less likely to overfeed and cause childhood obesity
  • Lowers the incidence of SIDS
65
Q

What vaccine do we need parental consent for?

A

Hep B

100% will become immune if given vaccine within 12 hours of life.

66
Q

What does puerperal infection pertain to?

A

Infection from chilbirth.

May involve placental site, laceration, episiotomy, or C-section incision.

8% of births
20% of C-sections

Maternal health (5 decks)

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