OB EXAM 2

forceps-assisted birth

- 2 curved spoon like blade to assist delivery of fetal head. traction applied - client presentation: prolonged second stage of labor and need to shorted duration (mom exhaustion), fetal distress during labor, abnormal presentation or a breech position, arrest of rotation - prep: explain procedure, lithotomy position, empty bladder, fetus engaged and membranes ruptured - ongoing: assist with procedure - interventions: assess and record FHR before during and after (compression of cord causes decrease in FHR, if FHR decreases, the forceps are removed and reapplied ), observe the neonate for bruising and abrasions at the site of forceps application after birth, check for injuries after birth (vaginal or cervical lacerations indicated by bleeding in spite of contracted uterus, uterine retention resulting from bladder or urethral injuries, hematoma formation in the pelvic soft tissues from blood vessel damage), report to postpartum that forceps was used - complications: lacerations of cervix vagina and perineum, injury to bladder, facial nerve palsy of the neonate, facial bruising on the neonate

fetal distress

- FHR below 110 or above 160, decrease or no variability, fetal hyperactivity or no activity - expected findings: non reassuring FHR pattern with decreased or no variability - dx procedures: monitor uterine contractions, monitor FHR, monitor findings of ultrasound and any other prescribed diagnostics - risk factors: fetal anomalies, uterine anomalies, complications of labor and birth - nursing care: monitor vs and fhr, position client in a left side lying reclining position with legs elevated, admin face mask oxygen, discontinue oxytocin if being admin, increase IV fluid rate to treat hypotension if indicated, prepare client for emergency c section

comfort level

- assess pain from episiotomy, lacerations, incisions, after pains and sore nipples - assess location, type , and quality of pain, admin pain meds as prescribed

sibling adaptation

- assessment: - positive responses: interest and concern for baby, increased independence - adverse response: rivalry and jealousy, regression in toiling and sleep, aggression towards infant, increased attention seeking behaviors and whining - nursing actions: take sibling on tour in OB, encourage parent to ( let sibling be one of the first to see baby, provide gift from baby to sibling, arrange for one parent to spend time with sibling, allow older siblings to help with care, provide pre school age with doll to care for

indications of potential complications after discharge

- chills or fever for more than 2 days - change in vaginal discharge (increased amounts, large clots, change to previous lochia color: bright red and foul smell) - epiostomy laceration or incisional pain that doesn't revolve with analgesics, foul smelling drainage redness and or edema - breasts with localized areas of pain and tenderness with firmness heat and swelling and or nipples with cracks redness bruising blisters or fissures - calves with localized pain tenderness redness and swelling - urination with burning, pain, frequency, urgency, cloudy or blood - postpartum depression: feels apathy toward infant and cannot provide care for self or baby, should have follow up visit 4-6 weeks, after c section follow up should be in 2 weeks, date and time of followin up should be verbalized and written down during discharge

meds for infection:

- clindamycin, cephalosporins, pencillin, gentamicin

uti

- common postpartum infection secondary to bladder trauma or ascetic technique for catheter - progression to pylenophritis with permanent kidney damage leading to kidney failure - risks: hypotonic bladder or urethra (stasis and retention), epidural, catheter, frequent pelvic exams, genital tract injuries, history of uti, c section - expected findings: urgency, frequency, dysuria, and discomfort, fever, chills, malaise, change in vs, elevated temp, ruine (cloudy, blood, malodorous, sediment visible), retention, pain in surpapubic area, pain at costovertebral angle (pylenophritis) - nursing careL clean catch, antibiotics, acetaminophen, perineal hygiene, 3000ml fluid intake, cranberry and prune juice

assessing for client knowledge of postpartum care

- inquire clients current knowledge about self care - assess clients home support system - determine clients readiness for learning and her ability to verbalize or demonstrate the info she has been given

mastitis

- milk status from blood duck, nipple trauma and cracked or fissured nipple, poor breast feeding technique, decrease in breast feeding, poor hygiene

nursing care of depression

- monitor interactions between mom and baby, mood and affect, reinforce feeling down is normal and self limiting, communicate feelings, compliance with meds, community resource, ask about self harm or infant harm - meds: antidepressants, antipsychotics, mood stabilizers - client ed: rest when infant does, taking time for herself, follow up visit, community resources, seek counseling

nursing interventions post partum con

- nutrition: diet high in protein which adds tissue repair, 2-3 L of fluid each day, non lactation:1800-2200 kcal a day, lactating increase 330 calories/day first 6 months, 450-500 calories, day to their pre pregnancy diet, and calcium enriched foods - postpartum exercises: regain pelvic floor muscle control with kegels 10-8 times a day, pelvic told exercise to strengthen back muscle to relieve strain on lower back - sexual intercourse: avoid until after episiotomy/laceration is healed and vaginal discharge has turned white, takes 2-4 weeks or until client is seen by provider, physiological rxxn during sex can be slower and less intense for 3 months following birth - contraception: use of contraception upon resumption of sex and pregnancy can occur while breast feeding even though menses has not returned, lactating should know contraceptives should not be taken until milk production is well established usually 4 weeks, menses for non lactating clients might not resume until 4-10 weeks, but ovulation can occur as early as 1 month, menses for lactating clients might not resume for 3 months or until cessation of breastfeeding

expected findings depression

- postpartum blues: sadness, lack of appetite, inadequate feelings, crying for no reason, restless, insomnia, fatigue, headache, anxiety, anger, sadness, crying - postpartum depression: guilt, inadequate, irritable, anxiety, fatigue persisting, feeling of loss, lack of appetite, sadness, intense mood swings, sleep disturbance, crying, wight loss, flat affect, irritability, rejection of infant, anxiety and panic attack - postpartum psychosis: pronounced sadness, wight loss, flat affect, confusion, irritated, rejection of infant, severe anxiety and panic attack , behaviors of hallucinations or delusions thoughts of self hard or harming baby

augmentation of labor

- stimulation of hypotonic contractions once labor has spontaneously begun, but progress is inadequate - risk factors: admin procedures, nursing assessments and interventions, possible procedure complications are the same for labor inductions

chapter 18

baby friendly care

coagulopathies

- ITP: autominne disorder which the life span of platelets is decreased by antiplatelt antibodies. can result in severe hemorrhage following c section or lacerations - DIC: clotting and anticlotting mechanism occur at the sam time. client is at risk for internal and external bleeding as damage to oranges resulting from ischemia caused by micro clots - coagulopathies are suspected when the usual measures to stimulate uterine contractions fail to stop vaginal bleeding - risk factors: ITP( genetic in origin), DIC (can occur secondly to other complications: aburptio placentae, amniotic fluid embolism, missed abortion, fetal death in utero, severe preeclampsia or eclampsia, HTN, HELLP, septicemia, hemorrhage, hydatidiform mole - expected findings: unusual spontaneous bleeding from gums and nose, oozing tricking or flow of blood from incisions, petechiae and ecchymoses, excessive bleeding from venipuncture, hematuria, GI bleed, tachycardia, hypotension, diaphoresis, oliguria - nursing care: assess skin, venipuncture, injections, lacerations, episiotomy, vs and hemodynamics, urinary output, transfuse platelet, assist for splenectomy if ITP does not respond to medical management - DIC: correct underlying problem, admin fluid volume replacement, admin meds, admin oxygen, provide protection from injury - therapeutic procedure: correct underlying cause, volume expansion, blood products, and clotting factors, optimize oxygen, splenectomy, hysterectomy for DIC

cervical ripening

- Increases cervical readiness for labor through promotion of cervical softening, dilation and effacement - can eliminate need for oxytocin, lower dosages and promote more successful induction - low dose infusion of oxytocin is used for cervical priming - mechanical and physical methods: balloon catheter into intracervical canal to dilate cervix, membrane stripping and an amniotomy may be performed, hygroscopic dilators may be inserted to absorb fluid from surrounding tissues and then enlarge. fresh dilators may be inserted if further dilation is required (laminaria, synthetic dilators) - chemical agents: based on prostaglandins to soften and thin cervix. oral or vaginal suppositories/gel. (misoprostol: prostaglandin E1, dinoprostone: prostaglandin E2) - indications: augmentation or induction is indicated - client presentation: failure of cervix to dilate and efface, failure of labor to progress

expected findings

- PUERPERAL INFECTIONS: flu like symptoms; body aches, chills, fevers, and malaise, anorexia nausea. elevated temp for at least 2 days, tachycardia - endometritis: pelvic pain, chills, fatigue, loss of appetite. uterine tenderness and enlargement, dark profuse lochia, lochia that is malodorous or purulent,temp typically on 3rd or 4th day, tachycardia - mastitis: painful or tender localized hard mass and reddened area usually on one breast, chills, fatigue., axillary adenopathy in affected side with inflammation that can be red swollen and warm and tender - wound infection: wound warmth erythema tenderness pain edema seropurulent daring and wound dehesicnce or evisceration, temp greater than 2 days

uterine atony

- Results from inability of uterine muscle to contract adequately after birth and can lead to postpartum hemorrhage - risk factors: retained placental fragments, prolonged labor, oxytocin induction or augmentation of labor, over distended uterus, precipitous labor, magnesium sulfate admin as tocolytic, anesthesia and analgesia admin, trauma during labor and birth from operative birth - expected findings: increased vaginal bleeding, uterus that is larger and boggy with lateral displacement on palpation, prolonged local discharge, irregular or excessive bleeding, tachycardia, hypotension, skin that is pale, cool and clammy with loss of turgor and pale mucous membranes - nursing care: empty bladder, monitor fungal height consistency and location and lochia for quantity color and consistency, perform fundal massage: if still uterine atomy assuming hysterectomy, express clots that can have accumulated in the uterus but only after the uterus is firmly contracted. it is critical to not express clots prior to the uterus becoming firmly contracted because pushing on uncontracted uruters can invert uterus and result in extensive hemorrhage, vs, iv fluids, oxygen on nasal cannula -medsL: postpartum hemorrhage client ed: instruct client to limit physical activity to conserve strength and increase iron and protein intake to promote rebuilding of abc volume

amnioinfusion

- amnioinfusion of normal saline or lactate ringer is instilled into the amniotic cavity through transcervical catheter introduced into the uterus to supplement the amount of amniotic fluid. instillation reduces the severity of variable decelerations caused by cord compression. - indications (potential diagnoses): oligohydramnios (scant amount or absence of amniotic fluid) caused by any of the following: uteroplacental insufficiency, premature rupture of membranes, postmaturity of the fetus. fetal cord compression secondary to postmaturity of fetus - interventions: assist with amniotomy if not already rupture, warm fluid prior to infusion, comfort and dryness, prevent uterine overdistension and increased urine tone, assess intensity and frequency of contractions, monitor FHR, monitor uterine output

amniotomy

- artificial rupture of the amniotic membranes (AROM) with an amnihook or other sharp instrument - labor begins within 12 hr after the rupture and can decrease the duration of labor by up to 2 hr - client is at increased risk for cord prolapse - indications: labor progression is too slow and augmentation or induction is indicated, indicated for cord compression - ongoing care: ensure the presenting part of the fetus is engaged prior to procedure, monitor FHR prior and immediately after AROM, assess and document characteristics of amniotic fluid including color, odor and consistency - interventions: document time of rupture, obtain temp every 2 hours, provide comfort measures

funds assessment

- assess fundal height, uterine placement, and uterine consistency at least every 8 hours after the recovery period has ended: explain procedure apply clean gloves and lower perineal pad, and observe lochia flow as the fundus is palpated, cup one hand just above the symphysis pubis to support the lower segment of the uterus and with the other hand, palpate the ab to locate the fundus, document the fundal height, location, and uterine consistency (determine the fundal height by placing fingers on the ab and measuring how many finger breadths fit between the funds and umbilical level, determine whether the funds is midline in the pelvis or displaced laterally: caused by full bladder, determine whether the funds is firm or boggy: if boggy lightly massage the fundus in circular motion) - patient centered care: admin oxytocin IM or IVafter placenta delivery (oxytocics: oxytocin, methylergonovine, and carboprost. misoprostol, a prostaglandin can also be admin), monitor for adverse effects (oxytocin and misoprostol can cause hypotension. methlergonovine, carboprost, and ergonovine can cause hypertension), encourage early breast feeding for lactating pt: stimulates natural oxytocin and prevents hemorrhage, empty bladder every 2-3 hours to prevent uterine displacement and atony

nursing care dysfunctional labor and hypertonic contractions

- assist with application of fetal scalp electrode and or intrauterine pressure catheter, assist with amniotomy, regular voiding, position change (hands and knees to rotate baby from posterior to anterior), ambulation, hydrotherapy and relaxation techniques, counter pressure using fist or heel of hand to sacral area to relieve pain, beneficial position for pushing and teach how to bear down, prepare for forceps vacuum or c section, monitor FHR - hydrate, rest and relaxation, comfort measures between contractions, lateral position and oxygen by mask - meds: analgesics if prescribed for rest form hypertonic contractions. oxytocin to augment labor, do not use when hypertonic contractions

psychosocial and maternal adaptation

- begin during pregnancy as the client goes through commitment, attachment, and prep of birth - first 2-6 weeks after birth client goes through aquaintance with baby and physical restoration and competently caring for her newborn, maternal identity is achieved 4 months following birth

prolapsed umbilical cord nursing care

- call for assistance immediately - notify provider - use sterile gloved hands, insert 2 fingers into vagina and apply finger pressure on either side of the cord to the fetal presenting part to elevate off cord - reposition client in a knee chest, trendelenburg, or side lying position with rolled towel under clients right or left hip to relieve pressure from cord - apply warm, sterile, saline-soaked towel to the visible cord to prevent drying and to maintain blood flow - monitor FHR for variable decelerations (fetal asphyxia and hypoxia) - face mask for fetal oxygen - initiate IV - prepare for immediate vaginal birth if cervix is dilated or c section if not dilated

musculoskeletal

- changes reversal of musculoskeletal adaptations that occurred during pregnancy. by 6-8 weeks after birth: - joints return to prepregnant state, feet can remain permanently bigger - muscle tone is restored with removal of progesterone, rectus abdomens muscles of ab and pubococcygeus muscle are stored after placental expulsion and return to prepregnant state about 6 weeks postpartum - assessment: ab wall for diastasic rectified from 2-4cm. usually resolves within 6 weeks - patient care: strengthening exercises, c section postpone ab workouts until 4 weeks after delivery, good body mechanics and proper posture

vaginal birth after c section (VBAC)

- client delivers vaginally after having previous c section - indications: no other uterine scares or hx of previous rupture, one or 2 previous low transverse c sections, adequate pelvis, providers available, no contraindications (large for gestational age newborn, malpresentation, cephalopelivic disproportion, previous classical vertical uterine incision) - nursing actions: review medical records for previous low segment transverse c section incision - client ed: explain procedure - intraprocedure: assess FHR during labor, record contraction patterns for strength, duration, and frequency, uterine rupture, promote relaxation and breathing techniques, provide analgesia as prescribed and requested - postprocedure: same as vaginal delivery

induction of labor considerations

- client preparations: prepare client for cervical ripening: (consent, if cervical ripening agents are used: baseline data on fetal and maternal well being, oxytocin 6-12 hr after admin of prostaglandin, monitor FHR and. uterine activity after cervical ripening agents, notify provider if uterine hyperstimulates or fetal distress is noted), prepare client for an aminotomy or amniotic membrane stripping. prepare client for oxytocin (ensure fetus is engaged in birth canal at min station 0 prior, infusion port closest to client for admin. oxytocin should be connected piggyback to main IV line admin via infusion, intrauterine pressure catheter may be used to monitor frequency, duration, and intensity of contractions. assess mom BP, pulse, and respirations every 30-60 min and with every change in dose, asses fluid i&o, bishop score prior to any induction protocol) - ongoing care: assist with or perform admin of labor induction agents (increase oxytocin as prescribed until desired contraction pattern and then maintain dose there; contraction frequency of 2-3 mins, contraction duration 60-90 sec, contraction intensity of 40-90 mm hg on iupc, uterine resting tone of 10-15 mm hg on iupc, cervical dilation of 1cm/hr, reassuring for between 110-160), discontinue oxytocin if uterine hyper stimulation occurs: (contraction frequency more than every 2 mins, contraction duration longer than 90 secs, intensity that results in pressure greater than 90 by iupc, uterine resting tone greater than 20 between contractions, no relaxation of uterus between contractions)

uterine rupture

- complete rupture involves uterine wall, peritoneal cavity, and or broad ligament, internal bleeding present - incomplete rupture occurs with dehiscence at the site or a prior scar ( c section, surgery). internal bleeding might not be present - rare but life threatening - risk factors: congenital uterine abnormality, uterine trauma due to accident or surgery, overdistension of uterus from big baby multi gestation or polyhydramnios, hyperstimulation of uterus, external or internal fetal version done to correct malposition of fetus, forceps birth, multigravida - expected findings: ripping or tearing sensation or sharp pain, ab pain, uterine tenderness, nonreassuring FHRm change in uterine shape and fetal parts palpable, cessation of contractions and loss of fetal station, manifestations of hypovolemic shock (tachycardia, hypotension, pallor, and cool clammy skin - nursing care: admin IV fluids, admin oxygen, admin blood products, prepare for c section that can involve laparotomy or hysterectomy

induction of labor

- deliberate initiation of uterine contractions to stimulate labor before spontaneous onset to bring about the birth by chemical or mechanical means - methods: mechanical or chemical approaches, admin of oxytocin IV, nipple stimulation to trigger the release of endogenous oxytocin - indications: any condition that augmentation or induction of labor is indicated. elective induction for nonmusical indications must meet criteria of at least 39 weeks of gestation and a bishop score greater than 8 for a multiparous and greater than 10 for a nulliparous. elective inductions that do not meet recommended criteria can result in increased risk for infection, premature delivery, longer labor, and need for c section. - client presentation: poster pregnancy (greater than 42 weeks), dystocia (prolonged, difficult labor) due to inadequate uterine contractions, prolonged rupture of membranes predisposes the client and fetus to risk of infection, maternal medical complications (Rh-isoimmunization, DM, pulmonary disease, gestational HTN), fetal demise, chorioamnionitis

c section

- delivery through transab incision of uterus to preserve life of client and fetus - dx: malpresentation (breech), cephalopelvic disproportion, non reassuring fetal heart tones, placental abnormalities, placenta previa, abruption placentae, high risk pregnancy (positive HIV, HTN (preeclampsia, eclampsia, DM, active genital herpes lesions), previous c section, multiple gestations, umbilical cord prolapse - actions: FHR, VS, ultrasounds, supine with wedge, catheter, consent, compression stocking, preop meds, prepare surgical site, insert IV, NPO since midnight, preop dx tests especially Rh-factor test - client ed: explain procedure, emojified support - intraprocedure: positioning, monitor FHR, VS, IV fluids, urinary output, instrument and sponge count - postprocedure: monitor infection, excessive bleeding at incision, uterine funds for firmness or tenderness, assess lochia for amount and characteristics, productive cough, chills, thrombophlebitis, I&o, VS, pain relief and antiemetics, turn and encourage cough and deep breathing, splinting, ambulation, burning or pain on urination - complications: mom (aspiration, amniotic fluid pulmonary embolism, wound infection, wound dehiscence, severe ab pain, thrombophlebitis, hemorrhage, UTI, injuries of bladder or bowel, anesthesia complications), fetal: premature birth of fetus, fetal injuries during surgery

phases of role attainment

- dependent: takin in phase.first 24-48 hours, meeting personal needs, rely on others for assistance, excited, talkative, need to review birth experience with others - dependent-independent: taking hold phase. begins day 2-3, lasts several days to weeks, focus on baby care and improving caregiving competencies, want to take charge but need acceptance from others, want to learn and practice, dealing with physical and emotional discomforts and experience baby blues - interdependent: letting go phase, focus on family as a unit, resumption of role (intimate partner, individual) - assessment: clients condition after birth, observing maternal adaptation, assessing mom emo readiness to take care of infant and seeing how comfy she is - behaviors that facilitate and indicate mother-infant bonding: considers infant a family member, holds baby face to face, assigns meaning to infants behavior and views it positively, identifies infants unique characteristics and relates them to those of other family members, names infant, touches infant and maintains close physical proximity and contact, provides physical care for the infant such as feeding and diapering, responds to infants cry, smiles talks and sings - behaviors that lack mother infant bonding: apathy when infant cries, disgust when infant voids stools or spits up, expresses disappointment in infant, turns away from infant, does not seek close proximity, does not talk about unique features, handles roughly, ignores, does not include in family context, receives infant as uncooperative - assess for manifestations of mood swings, conflicts about maternal role, or personal insecurity: feels down, inadequate, anxiety related to ineffective breastfeeding, emotional liability with frequent crying, flat affect and being withdrawn, unable to care for infant

dystocia (dysfunctional labor)

- difficult or abnormal labor related to the five P's (passenger, passageway, powers, position, and psychological response) - atypical uterine contraction patterns prevent the normal process of labor and its progression. contractions can be hypotonic or hypertonic with failure to efface and dilate the cervix - risk factors: short stature, overweight status, age greater than 40, uterine abnormalities, pelvic soft tissue obstructions or pelvic contracture, cephalopelvic disproportion (fetal head is larger than maternal pelvis), congenital anomalies, fetal macrosomia, fetal malpresentation or malposition, multifetal pregnancy, hypertonic or hypotonic uterus, maternal fatigue, fear or dehydration, inappropriate timing of anesthesia or analgesics - expected findings: lack of progression in dilation, effacement, or fetal descent during labor (hypotonic: easily indentable, even at peaks of contraction. hypertonic: cannot be indented, even between contractions), client is ineffective in pushing with no voluntary urge to bear down (persistent occiput posterior presentation is when the fetal occiput is directed toward the posterior maternal pelvis rather than the anterior pelvis, and the posterior position prolongs labor and client reports greater back pain as the fetus presses against moms sacrum - dx and therapeutic procedures: ultrasound, amniotomy or stripping of membranes if not ruptured, oxytocin infusion, vacuum assisted birth, c section

precipitous labor nursing care

- do not leave client unattended, -encourage pant with an open mouth between contractions to control the urge to push -side lying position, prepare rupture of membranes upon crowning, do not try to stop delivery - control rapid delivery by applying light pressure to the perineal area and fetal head gently pressing upward toward the vagina: eases rapid expulsion of fetus and prevents cerebral damage to new born and perineal lacerations (deliver fetus between contractions assuring the cord is not around the fetal neck, if it is attempt to gently slip it over the head. if not possible, clamp the cord with two clamps and cut between the clamps) - suction mucus from the fetal mouth and nose with a bulb syringe when the head appears - deliver anterior shoulder under maternal symphysis pubis then posterior shoulder and then the rest of the body - assess for complications: (mom: cervical vaginal or perineal lacerations, resultant tissue trauma secondary to rapid birth, uterine rupture, amniotic fluid embolism, postpartum hemorrhage. fetal: fetal hypoxia due to hypertonic contractions or umbilical cord around fetal neck, fetal intracranial hemorrhage due to head trauma from rapid birth).

complications:

- emo detachment and inability to care for infant - failure to bond with infant increases emo and physical abuse risk nursing actions - emphasize verbal and nonverbal communications skills between client, caregivers and infnt - proved continue assessment - support of family members - home visits and group sessions - social networks - outreach programs - notify programs that provide prompt and effective interventions

phases of role attainment nursing considerations

- facilitate bonding by skin to skin immediately after birth - promote rooming in as a quiet and private env, and promote early initiation of breast feeding and encourage the client to recognize infant readiness cues. offer assistance as needed - teach infant care facilitates bonding as confidence improves - encourage parents to bond with infant through cuddling, bathing, feeding, diapering, and inspection - provide frequent praise, support and reassurance, encourage feeling expression

paternal adaptation

- father has skin to skin, observes infant for features similar to him, talks sings and reads to the infant - transition: - expectations and intentions: father desire to be deeply and emotionally connected with the infant - confronting reality: expectations might not be met, commonly expressed emotions include feeling sad, frustrated, and jealous. embraces the need to be active in parenting - creating the role of the involved father: the father decides to become actively involved in the care of the infant - reaping rewards: infant smiles and a sense of completeness and meaning - assessment: hands on approach and ed with dad, assist dad in transition and provide guidance, encourage couples to verbalize concerns and expectations

pulmonary embolus

- fragments or an entire clot dislodges and moves into circulation, is a complication of dat that occurs if the embolus moves into pulmonary artery or ones of its branches and lodges a lung, occluding the vessel and obstructing blood flow into lungs, acute is emergent situaiton - risk factors: same as dvt - expected findings: apprehension, pleuritic chest pain, dyspnea, tachypnea, hemoptysis, heart murmur, distended neck veins, elevated temp, hypotension, hypoxia - dx and therapeutic procedures: ventilation, perfusion lung scan, chest radiographic study, radioisotope lung scan, pulmonary angiogram, embolectomy to surgically remove embolus - nursing careL semi fowlers, admin oxygen - meds: same as dat. alteplase, streptokinase: thrombolytic therapy to break up blood clots

post partum physiological assessment

- immediately follows delivery with VS, uterine firmness and its location in relation to the umbilicus, uterine position in relation to to the midline of the ab, and amount of vaginal bleeding (bp and pulse be assessed every 15 mins for first 2 hours, temp assessed every 4 hours for first 8 hours, and then at least every 8 hour) - focused postpartum assessment: BUBBLE (breasts, uterus: fundal height, uterine placement, and consistency, bowel, bladder, lochia: color, odor, consistency, and amount, episiotomy), vs and pain, teaching needs - lab tests: abc with monitoring of hgb, act, and abc and platelet counts - dx and therapeutic: rh negative mother (rho d immune globulin: given within 72 hours, kleihauer betke test: 15ml or more of fetal blood mom gets Rho d immune globulin)

episiotomy

- incision made into the perineum to enlarge the vaginal opening to facilitate birth and minimize soft tissue - indications: shorten of second stage of labor, forcep or vacuum delivery, prevent cerebral hemorrhage in preterm fetus, facilitate birth of macrocosmic infant - considerations: site and direction of the incision designates the type of episiotomy - median (midline): extends from vaginal outlet toward the rectum and most commonly used (effective, easily repaired, generally least painful, higher incidence of third and fourth degree lacerations) - mediolateral episitomy: extends from vaginal outlet posterolacteral, either left or right of midline and is used when posterior extension is likely (3rd degree laceration can occur, blood loss is greater and repair is more difficult and painful, local anesthetic is admin to perineum prior to incision - ongoing care: encourage alternate labor positions to reduce pressure on the perineum and promote perineal stretching to reduce the necessity for an episiotomy

fundus

- involution of the uterus and occurs with contractions where uterus changed back to prepregnant state. rapidly decreases in size from 1 kg to 60 to 80 g at 6 weeks with the fundal heigh steadily descending into pelvis approximately one finger breadth (1cm) per day - end of 3rd stage of labor, the uterus should be papble at midline and 2 cm below halfway between the umbilicus and symphysis pubis - 1 hr after delivery the funds should rise to the level of the umbilicus - every 24 hr, the fundus should descend approximately 1-2cm. it should be halfway between the symphysis pubis and umbilicus by the 6 postpartum day. - after 2 weeks the uterus should lie within the true pelvis and should not be palpable

precipitous labor

- labor that lasts 3 hours or less from onset of contractions to the time of delivery - risk factors: hypertonic uterine dysfunction (nonproductive, uncoordinated, painful, uterine contractions during labor that are too frequent and too long in duration with no relaxation between contractions: uterine tetany. do not contribute to the progression of labor: cervical effacement, dilation, and fetal descent. can result in uteroplacental insufficiency leading to fetal hypoxia). oxytocin stimulation: administered to augment or induce labor by increasing intensity and duration of contraction multiparous client: can move through the stages of labor more rapidly - expected findings: during labor (low backache, ab pressure and cramping, increased or bloody vaginal discharge, capable uterine contractions, progress of cervical dilation and effacement, diarrhea, fetal presentation, station and position, status of amniotic membranes: intact or ruptured), post birth (asses maternal perineal area for indications of trauma or lacerations, neonatal color and for hypoxia, trauma to presenting part of neonate especially on cephalic presentation)

lacerations and hematomas

- lacerations that occur during labor and birth consist of tearing of soft tissues in the birth canal and include cervial, vulvar, vaginal, perineal, and or rectal areas - epiosotmy can extend and become a 3rd or 4th degree laceration - hematoma is a collection of 250-500 ml of clotted blood within tissues that can appear bulging blushes mass. can occur in the pelvic region or higher in the vagina or broad ligament - pain is distinguishable clinical finding of hematoma - client is at risk for hemorrhage or infection due to laceration or hematoma - risk factors: operative birth, precipitous birth, cephalopelvis disproportion, size (macrosomic infant), abornmal presentation or position, prolonged pressure of fetal head on vaginal mucosa, precious scarring of the birth canal from infection injury or operation, clients who are nulliparous, women who have louth skin with red hair - expected findings - laceration: sensation of oozing or tickling of blood, excessive rubra lochia with or without clots. vaginal bleeding even though the uterus is from and contracted. continuous slow trickle of bright red blood from vagina, laceration, episiotomy - hematoma: pain, pressure sensation in rectum (urge to defecate) or vagina, difficulty voiding. bulging, bluish mass or area of red purple discoloration on vulva perineum or rectum - nursing care: assess pain, inspect vulva, perineum, andrectum, assess episiotomy for extension into a 3rd or 4th degree laceration, evaluate lochia, vs and hemodynamic, identify source of bleeding, repair procedures, ice packs to treat small hematomas, pain meds, sits bath and perineal hygiene - therapeutic procedures: repair and sutures, ligation of the bleeding vessel or surgical incision for evacuation of the clotted blood from the hematoma

postpartum hemorrhage

- loses more than 500 ml blood after birth or more than 1000 after c section: hypovolemic shock and anemia - risk factors: uterine atony, over distended uterus, previous hx of uterine atony, prolonged labor, oxytocin induced labor, high parity, complications during birth, precipitous delivery, admin of magnesium sulfate during labor, lacerations and hematoma, version of uterus, sub involution of the uterus, retained placental fragments, coagulopathies (DIC) - expected findings: increase or change in local pattern, uterine atony (hypotonic or boggy), blood clots larger than a quarter, perineal pad saturation in 15 min or less, constant oozing, trickling or flank flow of bright red blood from vagina, tachycardia and hypotension, skin pale cool and clammy with loss of tumor, oliguria - nursing care: firmly massage utter, monitor vs, assess for source of bleeding, assess bladder for distention, maintain IV fluids, provide oxygen via nasal canal, elevate clients legs 20-30degrees - meds: oxytocin, methelergonovine, misoprotol, carboprosy tromethamine - client ed: limit physical activity to conserve strength to increase iron and protein intake to promote rebuilding of RBC andtp take iron with vit c

meconium-stained amniotic fluid

- meconium passage in the amniotic fluid during the antepartum period prior to the start of labor is typically not associated with an unfavorable fetal outcome - fetal had loss of sphincter control, allowing meconium to pass into the amniotic fluid - risk factors: increased incidence for meconium in the amniotic fluid after 38 weeks of gestation due to fetal maturity of normal physiological functions, umbilical cord compression results in fetal hypoxia that stimulates the vagal nerve in mature fetuses, hypoxia stimulates the vagal nerve which induces peristalsis of fetal GI tract and relaxation of anal spinchter - expected findings: amniotic fluid can very in color (black, green, yellow or brown, meconium stained amniotic fluid is often green. can be thin or thick), criteria for evaluation of meconium-stained amniotic fluid (often breech presentation and might not indicate fetal hypoxia, no changes in FHR, stained fluid accompanied by variable or late decelerations in FHR (ominous sign) - dx procedures: electronic fetal monitoring - nursing care: document color and consistency, notify neonatal resuscitation team to be present at birth, gather equipment needed for neonatal resuscitation team to be present, gather material for neonatal resuscitation, follow suction protocol (assess respiratory efforts, muscle tone and heart rate, suction mouth and nose with bulb syringe if respiratory efforts strong, muscle tone good, and heart rate greater than 100, suction vocal cords using endotracheal tube before spontaneous breaths occur if respirations are depressed, muscle tone decreased, and heart rate less than 100

induction of labor complications

- non reassuring FHR (abnormal baseline less than 110 or greater than 160, loss of variability, later or prolonged decelerations) - nursing actions: notify provider, position in side lie position, keep IV line open and increase rate to 200ml/hr unless contraindicated, admin oxygen, admin tocolytic terbutaline 0.25mg subq as prescribed, monitor for FHR and patterns in conjunction with uterine activity, document responses, prepare for c section if can't get reassuring FHR

cervical ripening considerations

- nursing actions (ongoing care): urinary retention, rupture of membranes, uterine tenderness contractions, vaginal bleeding, fetal distress - interventions: consent, baseline data on fetal and mom well being, void before procedure, document number of dilators and or sponges inserted during procedure, side lying position, assist with augmentation or induction of labor, monitor FHR and uterine activity after admin of cervical ripening, notify provider if uterine hyper stimulation or fetal distress is noted, nausea, vomiting, diarrhea, fever, uterine tachysystole, proceed with cause if pt has glaucoma, asthma, cardiovascular or renal disorders. - complications: hyperstimulation (admin subq injections of terbutaline), fetal distress (apply O2 via face mask at 10L/min, position client on left side, increase rate of IV fluid admin, notify provider)

nursing care for infections

- obtain vs, pain, fundal height, position, and consistency, lochia, incisions and lacerations, inspect breasts - puerperal: aseptic technique, proper hand hygiene, client hygiene, iv access, admin penicillins or cephalosporins, comfort measures, client ed, high protein diet for tissue healing - endometritis: collect vaginala nd blood cultures, iv antibiotics, analgesics, hand hygiene, maintain interaction with futs - wound infection: perform wound care, iv antibiotics, comfit measures, client hygiene - mastitis: breast hygiene, air dry nipples, infant position and latching, completely emptying breast, breast feed from unaffected breast and initiate let down reflex in affected breast, rest, analgesics, fluids, (3000ml a day), well fitting bra, antibiotics

prolapsed umbilical cord

- occurs when the cord is displaced, preceding the presenting, part of the fetus, or protruding through the cervix. this results in compromised fetal circulation - risk factors: rupture of amniotic membranes, abnormal fetal presentation, transverse lie, small for gestational age, unusually long umbilical cord, multifetal pregnancy, unengaged presenting part, hydramnios or polyhydramnios - expected findings: client reports that she feels something coming through her vagina. visulization or palpitation of the umbilical cord protruding from Introitus, FHR monitoring shows variable or prolonged deceleration, excessive fetal activity followed by cessation of movement; suggestive of severe fetal hypoxia

anaphylactoid syndrome of pregnancy (amniotic fluid embolism)

- occurs when there is a rupture in the amniotic sac or maternal uterine veins accompanied by high intrauterine pressure that causes infiltration of the amniotic fluid into mother circulation. it travels to and obstructs the pulmonary vessels and causes respiratory distress and circulatory collapse. it can occur within labor, birth, or 30 mins after birth - meconium stained amniotic fluid or fluid containing particulate matter can cause devastating maternal damage because it readily clogs the pulmonary veins completely - serious coagulation problems such as DIC - risk factors: multiparty and advanced maternal age, placenta previa or abruption, preeclampsia, eclampsia, oxytocin admin, DM, c section, forceps brith, uterine rupture, cervical laceration, meconium stained amniotic fluid - expected findings: sudden chest pain and SOB, respiratory distress coagulation failure, circulatory collapse - nursing care: admin oxygen, intubation and mechanical ventilation as indicated, cardiopulmonary resuscitation, IV fluids, side lie with pelvis tilted at 30 degree angle, blood products, indwelling catheter and measure hourly output, prepare for c section

nursing interventions for postpartum care

- perineal care: cleanse from front to back with warm after after each void and stool, blot perineal area, remove and apply perineal pads from front to back - breast care - lactating: skin to skin and initiate breast feeding within 1-2 hr after birth, well fitting supportive bra for duration of lactation, hand hygiene, completely empty breast after each feeing, allow to nurse on demand (8-12 times a day), massage breasts, feed until breast softens, alternate with each feeding, breast engorgemnt apply cool compress after feeding and warm compress prior to breast feeding, flat or inverted nipples: roll nipples between fingers just before feeding (breast shield between feedings), sore nipples apply small amount of breast milk to nipple and also to air dry after breast feeing, apply breast creams, fluid intake - non lactating: well fitting supportive bra continuously for the first 72 hours, suppression of lactation is necessary for clients who are not breast feeding (avoid breast stimulation and running warm water over breasts for prolonged periods of time), breast engorgemnt that can occur on 3rd or 5th day, apply cold compress for 15 mins on and 45 mins off and mild analgesics or anti-inflammatory meds - rest sleep: one daily rest period, rest when infant naps - activity: no heavy lifting for 3 weeks, nothing heavier than infant, avoid sitting for long periods of time with legs crossed, limit stair climbing for first few weeks, c section wait 4-6 weeks follow up visit before any strenuous activity. do not drive first 2 weeks or while taking opioids

cardiovascular system and fluid and hematologic status

- physical changes - cardiovascular system postpartum: decrease in blood volume (300-500ml blood loss during childbirth in uncomplicated vaginal delivery. 500-1000ml in a c section), diaphoresis and diuresis occurs in first 2-3 days, hypovolemic shock does not usually occur in response to the normal blood loss or labor and birth because of the expanded blood volume of pregnancy and the readjustment in the maternal vasculature which occurs in response to: elimination of placenta, diverting 500 ml of blood into maternal circulation, rapid reduction in the size of the uterus, putting more blood into the maternal systemic circulation - blood values, coagulation factors, and fibrinogen levels during puerperium: hct drops moderately 3-4 days then reach non pregnant levels by 8 weeks. first 4-7 days abc 20,000-25,000 are common, coagulation and fibrinogen levels increase during pregnancy and remain elevated for 2-3 weeks postpartum. hypercoagubility predisposes the postpartum client to thrombus and thromboembolism - vital sign changes: bp unchanged with uncomplicated pregnancy but can have insignificant increase, orthostatic hypotension within 48 hr from splanchnic engorgement, elevation of pulse, stroke volume, and cardiac output first hour them decreases to baseline 8-10 weeks, elevation of temp to 100.4 from dehydration during first 24 hours but returns to normal after 24 hr - assessment: cardiovascular and vs changes and monitor blood component changes, inspect legs for redness, swelling, and warmth which are indications of venous thrombosis - patient care: notify provider and perform prescribed interventions (early ambulation to prevent venous stasis and thrombosis, anti embolism stockings (remove when the ambulate), admin meds as prescribed

cervix, vagina, perineum

- physical changes: - cervix is soft directly after birth and can be edematous, bruised and have small lacerations. 2-3 days postpartum it shortens, regains it's form, and becomes firm with os gradually closing. lacerations can delay production of estrogen influenced cervical mucus and predisposing factor to infection - vagina which is distended gradually returns to its prepregnancy size with appearance of rugae and thickening of mucousa. muscle tone is never restored completely - soft tissues of perineum can be erythematous and edematous, especially in areas of an episiotomy or lacerations. hematomas or hemorrhoids can be present. pelvic floor muscles can be overstretched and weak - assessment: observe perineum for erythema, edema, and hematoma. assess episiotomy and lacerations for approximation, drainage, quantity, and quality (red trickle in early postpartum is normal) - patient care (perineal tenderness, laceration, and episiotomy): soften clients stools, proper cleaning to prevent infection (wash hands after voiding, squeeze bottle with antiseptic solution, front to back wipe, blot dry not wipe, antiseptic topical cream or spray, perineal pad should be changed from front to back after voiding or defecating), promote comfort measures (ice packs to perineum for first 24 hours to 48 hours to reduce edema and provide anesthetic effect, encourage sit baths twice a day, admin analgesia like nonopioids: acetaminophen, NSAIDS: ibuprofen, opioids: codeine, hydrocodone, can use PCA for opioids after c section or continuous epidural after c section, topical anesthetics (benzocaine spray), with hazel compression for hemorrhoids

breasts

- physical changes: include secretion of colostrum that occurs during pregnancy and 2-3 days immediately after birth. milk is produced 3-5 days after the delivery - assessment: breasts and the latching of breast feeding: colostrum (early milk) transitions to mature milk by 72 or 96 hours after birth (milk coming in), engorgement of the breast tissue as a result of lymphatic circulation, milk production, and temporary vein congestion, redness and tenderness of breast, cracked nipples and indications of mastitis, ascertain that the newborn who is breastfeeiding has latched correctly to prevent sore nipples, ineffective newborn feeding related to maternal dehydration, discomffort, and newborn positioning or difficulty with latching onto breast - patient centered care: encourage early breast feeding for lactating client, assist comfy position and different breast feeding positions (changing helps nipple soreness), importance of proper latch techniques (areola and nipple), importance of Brest feeding releasing oxytocin

GI system and bowel function

- physical changes: increased appetite following delivery, constipation with bowel evacuation delayed 2-3days after birth, hemorrhoids - assessment: bowel function, hunger, spontaneous bowel movement might not occur 2-3 days after delivery secondary to decreased intestinal muscle tone during labor and puerperium and prelabor diarrhea and dehydration, discomfort with defecation because of tenderness, episiotomy, lacerations, or hemorrhoids, assess rectal area for hemorrhoids, operative vagina birth and anal spinchter lacerations increase the risk of temp postpartum anal incontinence that usually resolves within 6 months - patient care: soften stools and promote bowel fx (early ambulation, increased fluids and fiber), stool softeners (docustae sodium) to prevent constiaption, enemas and suppositories are contraindicated for 3rd/4th perineal lacerations

lochia

- post birth discharge that contains blood, mucus and uterine tissue - 3 stages: lochia rubra (bright red, bloody, fleshy odor, small clots, transient flow increases during breast feeding and upon rising. lasts 1 to 3 days after delivery), lochia serosa (pinkish brown color and serosanguineius consistency. lasts from day 4-10 after delivery), lochia alba (yellow white creamy color, fleshy odor, lasts day 11-4-8weeks) - assessment: quantity of saturation on the perineal pad as being (scant: less than 2.5 cm, light 2.5-10, moderate more than 10, heavy one pad saturated within 2 hr, excessive blood loss: one pad saturated in 15 min or less or pooling of blood under butt) asses flow for normla color, amount and consistency (trickles from vaginal opening but flows more steadily during contractions. assess for pooled lochia on pad, massage uterus with ambulation can result in a gush of lochia with the expression of clots and dark blood that has pooled in the vagina, but soon decreases to trickle of bright red in early puerperium) - manifestations of abnormal lochia: excessive spurting of bright red blood (cervical or vaginal tear), numerous large clots, and excessive blood loss (hemorrhage), foul odor (infection), persistent lochia ruba beyond day 3 (placental fragments), prolonged flow of rubra or serosa (endometritis: fever, pain, ab tenderness)

thermoregulation

- postpartum chill that occurs within the first 2 hours puerperium. uncontrollable shaking chill immediately following birth. possibly related to a nervous system response, vasomotor changes, shift in fluids, and or the work of labor. normal unless accompanied by elevated temp - give warm blanket and fluid - assure client that chills are self limiting, and common that will only last a short while

ECV considerations

- preparation: consent, provider does ultrasound prior for: (fetal position, locate umbilical cord, assess placental placement to rule out previa, determine amount of amniotic fluid, determine fetal age, assess for anomalies, evaluate pelvic adequacy for delivery, and/or guide the direction of the fetus during procedure), NST, ensure Rho(D) immune globulin was admin at 28 weeks if mom is Rh-, admin IV fluid and tocolytics for uterus relaxation for easier manipulation - ongoing care: monitor FHR patterns for bradycardia and variable decels and 1 hr following procedure, VS, assess for hypotension (vena cava compression), pain, Rh- clients require Kleihauer-Betke test to detect for presence and amount of fetal blood in maternal circulation bc version can cause fetomaternal bleeding (if more than 15ml fetal blood is present, Rho(D) is administered to suppress the maternal immune response to fetal Rh+ blood) - interventions: monitor uterine activity: (contraction frequency, duration, intensity), rupture of membranes, bleeding until mom is stable, decrease in fetal activity

nursing care of DVT

- preventionL compression device until ambulation, bed rest .8hr perform active and passive range of motion to promote circulation, early and frequent ambulation postpartum, avoid prolonged standing sitting or immobility, elevate legs, avoid cross legs, fluids 2-3L a day, discontinue smoking, measure lower extremities for fitted elastic thromboembolic hose - management: encourage rest, facilitate bed rest and elevation above heart, continuous or intermittent warm moist compress, do not massage, measure leg circumference, provide thigh high anti embolism stocking, admin analgesics (NSAIDS), admin anticoagulants - meds - heparin: anticoagulant, IV for 3-5 days. protamine sulfate is he antidote. monitor aPTT (1.5-2.5 times the control level of 30-40 seconds). report bleeding of gums or nose, increased vaginal bleeding, blood in urine and frequent bruising - warfarin: anticoagulant. PO. phytonadione is antidote. monitor PT (1.5-2.5 times control level of 11-12.5 seances and INR of 2-3). report bleeding of gums or nose, increased vaginal bleeding, blood in urine and frequent bruising. use birth control to avoid pregnancy due to teratogenic effects of warfarin. oral contraceptives are contraindicated because of increased risk for thrombosis

physical changes

- puerperium includes physiological and psychological adjustments. between birth and return of reproductive organs to their normal non pregnant state. - physiological maternal changes: uterine involution, lochia flow, cervical involution, decrease in vaginal distention, alteration in ovarian function and menstruation, and cardiovascular, urinary tract, breast and GI tract changes - greatest risks are hemorrhage, shock, infection - oxytocin a hormone released from the pituitary gland coordinates and strengthens uterine contractions (breastfeeding stimulates the release of endogenous oxytocin, exogenous oxytocin can be admin postpartum to prevent hemorrhage, uncomfy uterine cramping is referred to afterpains - after delivery of placenta, hormones (estrogen, progesterone, placental enzyme insulinase) all decrease resulting in decreased blood glucose, estrogen, and progesterone levels - decrease estrogen = breast engrogement, diaphoresis and diuresis of extracellular fluid - decreased progesterone = increase in muscle tone throughout the body - decreased placental enzyme insulinase = reversal of the diabetogenic effects of pregnancy which lowers blood glucose levels immediately in the puerperium - lactating and non lactating women differ in the timing of the first ovulation and the resumption of menstruation - lactating: serum prolactin levels remain elevated and suppress ovulation (return of ovulation is influenced by breastfeeding frequency, the length of each feeding, and the use of supplementation, the infants suck affects prolactin levels, length of time to first postpartum ovulation is approximately 6 months.) - non lactating women: prolactin declines and reaches the pregnant level by 3rd week postpartum (ovulation occurs 27-75 days after birth, menses resume 4-6 weeks postpartum)

retained placenta

- remains in the uterus and prevents uterus from contracting - risk factors: partial separation of placenta, entrapment of a patirallty or completely separated placenta by a constricting ring of the uterus, excessive traction on the umbilical cord prior to complete separation of the placenta, placenta tissue that is abnormaly adherent to the uterine wall, preterm births - expected findings: uterine atony, sub involution or inversion, excessive bleeding or clots larger than a quarter, return of lochia rubra once it's lochia serosa, malodorous lochia or vaginal discharge - dx procedures: manual separation and removal of the placenta is done by the provider, d&c if oxytocics are ineffective in expelling the placental fragments - nursing care: monitor uterus for fundal height consistency andpsition, monitor lochia, vs, fluids, oxygen on nasal cannula, surgical interventions is bleeding is present and continue - meds: oxytocin, terbutaline

immune system

- rubella: titer less team 1:8 is admin subq of rubella or measles mumps and rubella (MMR) vaccine during postpartum to protect subsequent fetus. client should not get pregnant for 1 month after imunnization - hep b: newborn infected to mothers should receive hep b vaccine and immune globulin within 12 hours of birth - rh: all rh - moms that have rh+ baby must be given rho(d) immune globulin IM within 72 hr. test client that received rubella vaccine and rho(d) within 3 months to determine if immunity to rubella has developed - varicella: if has no immunity, varicella vaccine is admin before discharge. should not get pregnant for 1 month following immunization, second dose is given 4-8 weeks - tetanus diphtheria acellular pertussis vaccine: recommended for women who haven't previously had it. admin prior to discharge or as soon as possible in the postpartum period

DVT

- thrombophlebitis refers to thrombus that is associated with inflammation, one in lower extremities can be superficial or deep veins which are most often femoral, saphenous, or popliteal veins, and can cause pulmonary embolism - risk factors: pregnancy, c section, operative vaginal birth, pulmonary embolism or varicosities, immobility, obscurity, smoking, multiparty, age greater than 35, hx of thromboembolism, DM - expected findings: leg pain and tenderness, unilateral swelling warmth and redness, hardened vein over thrombosis, calf tenderness - dx: doppler ultrasound scanning, computed tomography, MRI - client ed: avoid taking aspirin or ibuprofen, use electric razor for shaving, avoid all, brush teeth gently, avoid massaging legs, avoid periods of prolonged sitting or crossing legs

inversion of uterus

- turning inside out of the uterus and can be partial or complete. emergency situation that can result in postpartum hemorrhage - risk factors: retained placenta, uterine atony, vigorous fundal pressure, abnormal adherent placental tissue, final implantation of the placenta, excessive traction applied to umbilical cord, short umbilical cord, prolonged labor - expected findings: pain in lower ab, vaginal bleeding: hemorrhage (complete inversion evidenced by a large red rounded mass that protrudes 20-30cm outside the introitus; partial inversion as evidenced by palpitation of smooth mass through dilated cervix), dizziness, low bp, increased pulse (shock), pallor - nursing care: assess for inverted uterus (visualize introitus, perform pelvic exam, maintain iv fluids, admin oxygen), stop oxytocin if being admin at the same time as inervsion, avoid excessive traction on umbilical cord, anticipate surgery if nonsurgical interventions and management are unsuccessful - meds: terbutaline

external cephalic version

- ultrasound guided hands on procedure to put fetus into a cephalic lie done at 36 to 37 weeks gestation. - high risk of placental abruption, umbilical cord compression, and emergent c section. - contraindications: uterine anomalies, previous c section, cephalopelvic disproportion placenta prevue, multifetal gestation, and oligohydramnios (deficiency of amniotic fluids) - indications: malpositioned fetus in a breech or transverse position after 36 weeks of gestation

urinary and bladder function

- urinary retention secondary to loss of bladder elasticity and tone and or loss of bladder sensation resulting from trauma, meds, or anesthesia, distended bladder as a result of urinary retention can cause uterine atony and displacement to one side, usually to the right. ability of uterus to contract is lessened - pospartal diuresis with increased urinary output begins within 12 hours of delivery - assessment: ability to void every 2-3 hours, assess bladder elimination pattern (more than 3000 ml/day is normal within first 2-3 days after delivery, evidence for distended bladder (fundal height over the umbilicus or baseline level, funds displaced from midline, bladder bulges above the symphysis public, excessive lochia, tenderness over the bladder area), frequent voiding of less than 150ml of urine is indicative of urinary retention with overflow - patient care: encourage every 2-3hour void, measure first few voids after delivery, encourage fluid intake, catheterize if necessary

vacuum-assisted delivery

- use of cuplike suction device that attaches to fetal head - conditions for use: vertex presentation, absence of cephalopelvic disproportion, ruptured membranes - associated risks: scalp lacerations, subdural hematoma of neonate, cephalohematoma, maternal lacerations to the cervix, vagina, or perineum - indications: maternal exhaustion and ineffective pushing efforts, fetal distress during second stage of labor, generally not used to assist birth before 34 weeks - prep of client: provide support and education, lithotomy position, record FHR before and during procedure, assess bladder distention and need for catheter - ongoing: prepare for a forceps-assisted birth if procedure not successful - interventions: tell postpartum about vacuum procedure, look for lacerations, cephalohematoma. or subdural hematoma after delivery, check the neonate for caput succedaneum (swelling of scalp in newborn that disappears within 3-5 days)

bishop score

- used to determine the maternal readiness for labor by evaluating if the cervix is favorable by rating dilation, effacement, consistency (firm, medium, or soft), position (posterior, mid position, or anterior), and presenting part station - 39 weeks > 8 for multiparous. > 10 for nulliparous for indication of readiness for labor induction

infections (endometritis, mastitis, and wound infections)

- uterine infection: endometritis. infection of uterine lining or endometrium. most common puerperal infection. begins on second to fifth postpartum date as a localized infection at the placenta attachment then spreading to entire uterus endometrium - wound infections: c section incisions, epiostomies, lacerations and any trauma wounds present in the birth canal - mastitis: infection of the Tittie involving interlobular connective tissue and is unilateral. can increase to access if untreated . most common in breast feeding owe for their first time , staph aureus is the organism - risk factors: uti, mastitis, pneumonia, hx of previous venous thrombus, hx of dm, immunosuppression, anemia, malnutrition, all or drug disorder, cervical dilation with exposure to external env, well supplied exposed blood vessels, wounds, alkalinity of body liquids during pregnancy and early postpartum period, c section, prolonged rupture of membranes, retain placental fragments and manual extraction, chorioamnionitits, internal fetal/uterina pressure monitoring, multiple vaginal examinations after rupture of membranes, prolonged labor, postpartum hemorrhage, operative vaginal birth, epidural analgesia/anastehsia, hematomas, episiotomy, lacerations

subimvolution of uterus

- uterus remains enlarged with continued lochial discharge and can result in postpartum hemorrhage - risk factors: pelvic infection and endometritis, retained placental fragments - expected findings: prolonged vaginal bleeding, irregular or excessive vaginal bleeding - physical assessment findings: uterus is enlarged and higher than normal in the ab relative to the umbilicus, boggy uterus, prolonged lochia discharge with irregular or excessive bleeding - dx procedures: dilation and cutter age (D&C) is performed to remove fragments - nursing care: monitor fundal position and consistency, monitor lochia, vs, activities to enhance uterine involution (breast feeding, early and frequent ambulation, frequent voiding, d&c can be necessary to remove retained placental fragments - meds: oxytocin, methylergonovine, antibiotcs

chapter 19

client ed and discharge

chapter 16

complications related to the labor process

risk factos

hormonal changes with rapid decline in estrogen and progesterone, postpartum physical discomfort or pain, individual socioeconomic facts, decreased social support system, anxiety about assuming new role, unplanned pregnancy, hx of depression, low self esteem, partner abuse

chapter 22

postpartum depression

chapter 20

postpartum disorders

chapter 21

postpartum infections

chapter 17

postpartum physiological adaptation

chapter 15

therapeutic procedures to assist with labor and delivery