OB Exam #4: Ch. 15
Anatomic changes reside quickly
- Diaphragm returns to its usual position - baby no longer pushing on diaphragm ! - Mom can breathe better!
urinary system
- Increased bladder capacity, swelling, bruising - Urine stasis - Epidural - puerperal diuresis
respiratory system
- Tidal volume, minute volume, vital capacity, and functional residual capacity return to prepregnant values within 1 to 3 weeks of birth - Anatomic changes reside quickly - RR will be WNL
ENGROSSMENT: PARTNER PSYCHOLOGIC ADAPTATION
- Visual awareness of the newborn - Tactile awareness of the newborn - Perception of the newborn as perfect - Strong attraction to the newborn - Awareness of distinct features of the newborn - Extreme elation by the father - Increased sense of self-esteem - Dad doesn't go through any physical changes like mom does
letting-go phase
- Woman reestablishes relationships with others - Two separate roles; adapting parental role and life changes that now have to include nugget - BAM (becoming a mother)
NANDA Nursing dx: Distorted Body Image
- Women feel better now that they are no longer pregnant, but they have the appearance of pregnancy - support! - Remind them it took 9 months to get there so it is going to take time to get back to normal
postpartum mood disorders
- baby blues - postpartum depression and psychosis
epidural
- decreases urine output - May not feel full bladder - straight cath !
RR will be WNL
- may be lower if pain medication is administered - Normal RR 16-20
colostrum
Clear/yellow, high in nutrients, proteins, & antibodies, sweeter, helps babies latch on
Prolactin
Helps stimulate milk production & inhibit ovulation
Oxytocin
Helps stimulates milk let down & uterine contraction
assess for attachment
Holding baby, looking at baby, talking to baby, has name for baby, interest in learning, baby in room
Prolactin levels remain high for breastfeeding
If not breastfeeding - will decrease in 2wk
swelling of the breast
Occur from infrequent feeding or ineffective emptying of the breasts
Oxytocin contributes to this!!! (natural!!)
Secreted from pituitary gland
Breastfeeding can contribute to oxytocin release!!!
Stimulates uterine contractions which in turn helps the uterus fold on itself
Transition to mastery
Take conscious control over "this is my life, this is my baby"
Expectations
They think about how life will be like with a newborn
Stretch marks fade to silvery lines
Typically on abdomen and breasts
full bladder
Uterus up and deviated to the right
blood volume
Vaginal - 500mL blood loss C-section - 1000mL blood loss More than that = hemorrhage risk!!
preeclampsia
may take longer to return to normal
amount of lochia
scant, small, moderate, large
slower HR, may be bradycardic
- It can run from 40-60 BPM - It will then return to baseline
color of lochia
- rubra - serosa - alba
Sitz baths
- warm water (vasodilate) - Hazel pads, anesthetic spray, peri bottle
alba
- white - 2-6 weeks - Consists of leukocytes, decidual tissue, and reduced fluid content
should return to pre-pregnancy level
Can be slightly lower the first two days PP
Blood clots
SCDs, walk. Fl, s/s to watch for, DVT, PE, chest pain, SOB, dyspnea
breasts need to be stimulated by
a nursing infant, a breast pump, or manual expression of milk
dyspareunia
(painful sex) may occur until menstruation returns - Water-soluble lubricants
Taking-in phase
- (24-48h after birth) - Immediately after birth when the client needs others to meet her needs (passive role) and relives the birth process (talkative, excited) - Passive—mom relies on nurse for feeding, changing, and what's going on with baby
typically descends from level of umbilicus at a rate of 1 cm/day
- 1/U—one above umbilicus - U/1—one below umbilicus
perineum
- Assess for hemorrhoids, episiotomy, laceration, bruised, edematous - ice pack - sitz baths - episiotomy - Episiotomy or laceration healing may take 4-6 months in the absence of complications (hematoma and infections) - KEGELS to improve pelvic floor tone
external cervix
- Before kids - circular - After kids - slit-like, never fully closes
taking-hold phase
- Dependent and independent maternal behavior - 2-3 days PP and can last for a few weeks, more autonomy/self-confidence to take care of baby—wants to do it independently - Still requires reassurance
Fear of using bathroom for BM following vaginal birth
- Encourage food, fiber, fluid, walking - Stool softener can be ordered
endocrine
- Estrogen, progesterone, placental hormones - decrease rapidly - Prolactin levels remain high for breastfeeding
Reality
- Expectations are not really realistic - Feelings change from elation to sadness, ambivalence, jealousy, and frustration - Feelings of ambivalence, frustration, male PP depression
cervix
- External: os never goes back to pre-pregnancy state - Internal: return to normal after 2wk
MATERNAL PSYCHOSOCIAL ADAPTATIONS: ATTACHMENT
- Formation of a relationship between a parent & newborn through a process of physical and emotional interactions - Early and sustained contact between newborns and parents - VITAL! - Nurses play a crucial role is assisting with this process of attachment
fundal checks
- Fundus goes down one finger breath each day of postpartum - U/U after birth - @ umbilicus at 24hr - Typically descends from level of umbilicus at a rate of 1 cm/day - Day 10 - can't feel/palpate
Breasts during pregnancy
- Inc levels of estrogen, progesterone stimulate breast duct proliferation & development - Each breast gains about 1lb in weight during pregnancy - Prolactin triggers synthesis/secretion of milk
OVULATION AND THE RETURN OF MENSTRUATION
- Interplay of hormones: estrogen, progesterone, prolactin, and oxytocin - lactating women - nonlactating women
musculoskeletal
- Joints return to prepregnant state except for feet (can be ½ size larger) - Fatigue and activity intolerance may occur - NANDA Nursing dx: Distorted Body Image - Good body mechanics and correct positioning are important during this time
baby blues
- Mild depressive symptoms, anxiety irritability, mood swings, tearfulness, increased sensitivity, fatigue - Hormones fluctuating - No sleep - sleep helps!!!! - Peaks 4-5 days end day 10
GI system
- NPO during labor - Bowels sluggish following birth - GI usually returns to normal quickly - Bowel sounds can be hypo when listening at first - Constipation is common - Fear of using bathroom for BM following vaginal birth
INTEGUMENT SYSTEM
- Pigmentation fades (linea nigra, chloasma) - Stretch marks fade to silvery lines - Hair loss after pregnancy most common during first 3mo (drop in estrogen)—should return to normal within 4-6 months - Diaphoresis common for about a week postpartum
coagulation
- Pooling and stasis of blood in the lower limbs place women at risk for blood clots - 2-3 wks PP stays elevated - still hypercoagulable - Blood clots! - Greater risk with history of smoking, obesity, immobility (c-section)
uterine involution
- Process of uterus returning to its normal size - After birth, uterus weighs 1000g---in one week it's half its size and is back to normal after 6 weeks - Contraction of smooth uterine muscles start to help it involute on itself (clamp down)
breasts once placenta expelled
- Progesterone and estrogen levels fall - Baby to breast - stimulate pituitary (prolactin & oxytocin) - cycle
Contraction of smooth uterine muscles start to help it involute on itself (clamp down)
- R/t decrease in estrogen/progesterone - oxytocin - pitocin
vagina
- Returns to normal at end of postpartum (6wk) -Normal mucus production & thickening of mucosa return with ovulation - Lactation amenorrhea - Dyspareunia
Early and sustained contact between newborns and parents - VITAL!
- Skin-to-skin and rooming in is encouraged - Baby is alert the first 30min after birth (reactive phase)—best time to breast feed! - En face position (face-to-face)
lochia
- Sloughing off of endometrial tissue - due to low progesterone - Amount - Should have fleshy smell - Foul odor indicates infection - Bright red - laceration (not sutured enough)
Process of uterus returning to its normal size
- Starts to close in/fold in on itself - Allows clamping down & constriction of blood vessels to stop bleeding
engorgement
- Swelling of the breast tissue due to an increase in blood flow & lymph supply as a precursor to lactation - Breasts will be hard and tender to touch - Relieved by frequent emptying, warm showers, pump, manually express, cold compress b/t feeds
Postpartum depression and psychosis
- Symptoms last longer and are more severe and require treatment - Poor bonding, alienation from loved ones, daily dysfunction and violent thoughts/actions - Feelings of restlessness, worthlessness, guilt, hopelessness, moody, sad, overwhelmed - 2wk checkup - EPDS screening tool!
If mom does not want to breastfeed
- Wear supportive bra - Ice when engorgement happens - DO NOT stimulate - will make more milk; analgesics to help with pain
cardiovascular system
- blood volume -pulse - BP - coagulation
lactation
- colostrum (first milk) - Prolactin increases at term with decrease of estrogen/progesterone
serosa
- dark brown/pink - 10 days - Leukocytes, decidual tissue, RBC, and serous fluid
Rubra
- dark red - 3-4 days - Deep-red mix of mucus, tissue debris, and blood
breasts
- during pregnancy - once placenta is expelled
DAD'S THREE STAGE ROLE DEVELOPMENT PROCESS
- expectations - reality - transition to mastery
subinvolution is caused by
- full bladder - retained placental fragments - atony
episiotomy
- pain, strain, BM, tear sutures - Fl, walking, fiber, colace
after pains
- part of involution - contractions - Oxytocin contributes to this!!! (natural!!) - Breastfeeding can contribute to oxytocin release!!! - Mild analgesic may be administered due to pain of contractions - Tylenol, Motrin - Standing order: Pitocin directly after birth!!
blood pressure
- should return to pre-pregnancy level - preeclampsia - decreased BP may suggest an infection or a uterine hemorrhage
pulse
- slower HR, may be bradycardic - You worry about tachycardia—this first sign of hemorrhage - Dehydration can occur
REVA RUBIN'S 3 PHASES
- taking-in phase - taking-hold phase - letting-go phase
B. "Oxytocin is released when the baby sucks, which causes the uterus to contract." Rationale Afterpains, which are intermittent cramping of the uterus, tend to be noticed by multiparas rather than primiparas. In this situation, the uterus must contract more forcefully to regain its prepregnancy size. These sensations are noticed most intensely while breastfeeding because the infant's sucking causes a release of oxytocin from the posterior pituitary, increasing the strength of the contraction
A 2-DAY POSTPARTUM CLIENT TELLS THE NURSE THAT SHE IS EXPERIENCING ABDOMINAL CRAMPS WHENEVER SHE BREASTFEEDS HER BABY. WHICH OF THE FOLLOWING IS THE MOST APPROPRIATE RESPONSE FROM THE NURSE? A. "Progesterone levels increase after birth of the placenta, which triggers milk production and uterine contractions." B. "Oxytocin is released when the baby sucks, which causes the uterus to contract." C. "The baby is feeding too frequently causing the uterus to be hyper-stimulated." D. "The cramps will stop after your body has expelled all blood clots from the uterus."
Prevent low back pain and injury to joints
After birth, muscle tone is diminished, and the abdominal muscles are soft and flabby
d. "I am concerned about what you are experiencing. Tell me more about what you are thinking and feeling." Rationale The nurse should convey empathy and invite the client to share more about her thoughts and feelings so that the nurse can assess the mother for possible postpartum depression, which usually occurs between 2 weeks and 3 months after the baby's birth but also can occur later. Postpartum depression is a mood disorder with symptoms of tearfulness, mood swings, despondency, feelings of inadequacy, inability to cope with the baby, and guilt about performance as a mother. Postpartum depression commonly goes undetected because of poor recognition and lack of knowledge
DURING A POSTPARTUM EXAMINATION, THE MOTHER OF A 2-WEEK-OLD INFANT TEARFULLY TELLS THE NURSE SHE FEELS VERY TIRED AND THINKS SHE IS NOT A GOOD MOTHER TO HER BABY. WHICH STATEMENT BY THE NURSE WOULD BE BEST? A. "The hormonal changes your body is experiencing are causing you to feel this way." B. "Most new mothers feel the same way that you do. I hear that a lot from others." C. "You need to have your husband and family help you so that you can get some rest." D. "I am concerned about what you are experiencing. Tell me more about what you are thinking and feeling."
B. uterine atony Rationale Because birth occurs so rapidly and the fetus is propelled quickly through the birth canal, the major complication of a precipitous birth is a boggy fundus, or uterine atony. The neonate should be put to the breast, if the mother permits, to allow for the release of natural oxytocin. In a hospital setting, the health care provider (HCP) will probably prescribe administration of oxytocin. The nurse should gently massage the fundus to ensure that it is firm.
DURING THE FIRST HOUR AFTER A PRECIPITOUS BIRTH, THE NURSE SHOULD MONITOR A MULTIPAROUS CLIENT FOR SIGNS AND SYMPTOMS OF WHICH COMPLICATION? A. postpartum "blues" B. uterine atony C. intrauterine infection D. urinary tract infection
A. The uterus is descending at the rate of one fingerbreadth per day. Rationale During the normal involutional process, the uterus will descend approximately one fingerbreadth per day. Blood pressure doesn't change during the postpartum period. Urine output typically increases after childbirth. Usually, the client will need six to seven perineal pads per day at this time.
DURING THE POSTPARTUM PERIOD, A NURSE SHOULD ASSESS FOR SIGNS OF NORMAL INVOLUTION. WHICH STATEMENT WOULD INDICATE THAT A CLIENT IS PROGRESSING NORMALLY? A. The uterus is descending at the rate of one fingerbreadth per day. B. Blood pressure drops as a result of the birth and changed circulatory load. C. Urine output remains about the same as in the client's prenatal period. D. Perineal pad usage remains at 10 to 15 per day.
Bowel sounds can be hypo when listening at first
Decreased peristalsis due to analgesics, surgery, diminished intra-abd pressure, low-fiber diet, insufficient fluid intake, diminished muscle tone
Estrogen, progesterone, placental hormones
Drop as soon as placenta is delivered
Pigmentation fades
Due to estrogen/progesterone levels going back to normal
Breasts will be hard and tender to touch
Full, tender, very uncomfortable
Dad doesn't go through any physical changes like mom does
He goes from being a partner/support system to a parent
bottle feeding moms
If the mother is bottle feeding: - Wear tight supportive bra 24 hrs/day - Apply ice to breasts - Avoid sexual stimulation - Avoid manually expressing milk - Avoid exposure to warmth * Remember - the more you stimulate, the more it comes in!!!
Good body mechanics and correct positioning are important during this time
Prevent low back pain and injury to joints
BECOMING A MOTHER (BAM)
RN has big role for the first 2 stages; assist the mom into becoming a mom 1. Commitment, attachment to unborn baby, preparation for delivery and motherhood during pregnancy (learn, classes, prenatal care) 2. Attachment to infant, learning to care for, and physical restoration 2-6 weeks post birth (postpartum) 3. Moving toward a new normal 4. Achievement of a maternal identity through redefining self to incorporate motherhood - around 4mo (teach ab self-care, baby care)
B. "They usually fade to a silvery-white color over a period of time." Rationale: Stretch marks, or striae gravidarum, are caused by stretching of the tissues, particularly over the abdomen. After birth, the tissues atrophy, leaving silver scars. These skin pigmentations will not disappear completely. The striae gravidarum may reappear as pink streaks if the client becomes pregnant again. Special creams are not warranted because they are not helpful and may be expensive. Weight loss does not make the marks disappear. Striae gravidarum tend to run in families.
WHILE THE NURSE IS ASSESSING THE FUNDUS OF A MULTIPAROUS CLIENT WHO GAVE BIRTH 24 HOURS AGO, THE CLIENT ASKS, "WHAT CAN I DO TO GET RID OF THESE STRETCH MARKS?" WHICH RESPONSE WOULD BE MOST APPROPRIATE? A. "As long as you don not get pregnant again, the marks will disappear completely." B. "They usually fade to a silvery-white color over a period of time." C. "You will need to use a specially prescribed cream to help them disappear." D. "If you lose the weight you gained during pregnancy, the marks will fade to a pale pink."
Interplay of hormones: estrogen, progesterone, prolactin, and oxytocin
estrogen decreases after birth, progesterone increases again after menstruation
Puerperal diuresis
excessive fluid excretion after childbirth - Pitocin - antidiuretic property (causes mom to hold onto fl), won't diuresis as much until Pitocin d/c - Sweating a lot (while they shower - change sheets & gown!)
subinvolution
incomplete involution of uterus
urine stasis
increased risk UTI
causes of Puerperal diuresis
large amounts IV fluids, d/c Pitocin, buildup/retention of fl during pregnancy
Cycle
more stim = more milk
Lactation amenorrhea
no period r/t breastfeeding, not a good contraceptive
contractions
occur to constrict blood vessels in uterine muscles
Bowels sluggish following birth
regardless of vaginal or cesarean birth
oxytocin
released by pituitary during breastfeeding
Lactating women
return dependent on freq/duration of feeds, anywhere from 2-18mo - Ovulation can still occur before menstruation despite breast feeding - NOT AN ACCURATE METHOD OF BIRTH CONTROL
nonlactating women
return of menstruation @ end PP (6wk)
atony
stretching of uterus - multiple births, macrosomia, hydramnios
pitocin
we give in hospital
