OB Exam 2 - Postpartum Adaptations & Complications

What uterine atony med cannot be given to pt with htn?*

Methergine

Where it the uterus immediately after birth?

Midline and halfway between symphysis pubis and umbilicus

Taking-hold phase

More independent and shift focus to infant Verbalize anxiety

What factors make afterpains more severe?*

Multiparas Overdistension Breastfeeding

Is breastfeeding a form of birth control?*

NO

Important teaching about siblings of new baby*

Need extra attention Need to be taught appropriate interaction

Postpartum chill

Normal after birth but later could indicate fever or infection

What does BP changes PP put a pt at risk of?

Ortho hypotension and falls

Lochia rubra

1-3 days, dark red

Which client is most likely to have the least stress adjusting to her role as a mother? 1. A 26-year-old woman who is returning to work in 10 weeks 2. A 35-year-old anxious mother who has had no contact with babies or children 3. A 16-year-old teenager who lives with her parents and has a strained relationship with her mother 4. A 25-year-old woman who knew at 16 weeks of gestation that she was pregnant with twins, who were delivered by cesarean birth

1. A 26-year-old woman who is returning to work in 10 weeks Has the least stressors

Which strategies should the nurse suggest to a postpartum client to promote stress reduction during the first weeks at home? (Select all that apply.) 1. Limiting coffee, tea, cola, and any caffeinated beverages 2. Maintaining a rigid schedule 3. Sleeping when the infant sleeps 4. Inviting visitors and friends to stop by frequently 5. Using learned breathing techniques from childbirth classes for relaxation

1. Limiting coffee, tea, cola, and any caffeinated beverages 3. Sleeping when the infant sleeps 5. Using learned breathing techniques from childbirth classes for relaxation

Mercer's Maternal Role Attainment

1. Anticipatory stage- choose Dr., look for role models, childbirth classes, & preparations 2. Formal stage- birth to 4-6 weeks. Depend on others for advice* 3. Informal stage- Learned infant's cues and make own decisions 4. Personal stage- feels comfortable and competent

CV - plasma changes PP

1. Diuresis and increase output 2. Fibrinogen elevated 3. Anemic with high WBC 4. Bradycardic

Which anticipatory guidance action by the nurse makes role transition to parenthood easier? 1. Helps the new parents identify resources 2. Recommends employing babysitters frequently 3. Tells the parents about the realities of parenthood 4. Offers a home phone number and tells parents to call if they have a question

1. Helps the new parents identify resources

A new father states, "I know nothing about babies," but he seems to be interested in learning. The nurse should take which action? 1. Include him in teaching sessions. 2. Tell him when he does something wrong. 3. Show no concern because he will learn on his own. 4. Continue to observe his interaction with the newborn

1. Include him in teaching sessions.

Meds to treat uterine atony

1. Methylergonovine (Methergine) 2. Carboprost Tromethamine (Hemabate) 3. Misoprostol (Cytotec)

The nurse is caring for a client who is in the "taking-in" phase of the postpartum period. The area of health teaching that the client will be most responsive to is: 1. Perineal care 2. Infant feeding 3. Infant hygiene 4. Family planning

1. Perineal care

Which are nursing measures that can promote parent-infant bonding and attachment? (Select all that apply.) 1. Provide comfort and ample time for rest. 2. Keep the baby wrapped to avoid cold stress. 3. Position the infant face to face with the mother. 4. Point out the characteristics of the infant in a positive way. 5. Limit the amount of modeling so the mother doesn't feel insecure.

1. Provide comfort and ample time for rest. 3. Position the infant face to face with the mother. 4. Point out the characteristics of the infant in a positive way.

4 causes of postpartum hemorrhage = 4 Ts

1. Tone - Uterine Atony 2. Tissue - Retained placenta, Placenta accreta 3. Trauma 4. Thrombocytopenia

Lochia alba

10 days- 6 weeks, white

How much hematocrit loss is considered hemorrhage?

10%

Moderate lochia

10-15 cm

What temperature after 24 hours can indicate an infection?*

100.4

How much blood loss can the body tolerate before going into hypovolemic shock?

1500 to 2000 mL

Postpartum psychosis

2 days after and beyond Confusion, agitation, hallucinations & delusions Psychiatric emergency

What does the nurse anticipate that a primipara with a second degree laceration and repair is most likely to develop during the post-partum period? 1. Posterior vaginal varicosities 2. Difficulty voiding spontaneously 3. Delayed onset of milk production 4. Maladaptive bonding with the newborn

2. Difficulty voiding spontaneously

Light lochia

2.5 to 10 cm

Signs of uterine atony

A uterine fundus that is difficult to locate A soft or "boggy" fundus A uterus that becomes firm as it is massaged but loses its tone when massage is stopped A fundus that is located above the expected level Excessive lochia, bright red Excessive clots expelled

The first day home from the hospital, baby Ryan's mother visited happily with relatives and then sobbed when everyone but her partner left. When the partner calls the office you provide information about: 1. Post-partum depression 2. Manic-depressive symptoms 3. Baby blues 4. Obsessive-compulsive disorder

3. Baby blues

Signs of PP hemorrhage

A uterus that does not contract or does not remain contracted Large gush or slow, steady trickle of blood from the vagina Saturation of one peripad per 15 minutes Severe, unrelieved perineal or rectal pain Tachycardia

A multiparous client is admitted to the postpartum unit after a rapid labor and birth of a 4000-g infant. Her fundus is boggy, lochia is heavy, and vital signs are unchanged. The nurse has the client void and massages her fundus, but the fundus remains difficult to find and the rubra lochia remains heavy. Which action should the nurse take next? 1. Recheck vital signs. 2. Insert a Foley catheter. 3. Notify the health care provider. 4. Continue to massage the fundus.

3. Notify the health care provider.

The nurse in the mother/baby unit is teaching self-care to her patient. What color does the nurse teach the lochial discharge will be on the fourth post-partum day? 1. Dark red 2. Deep brown 3. Pinkish brown 4. Yellowish white

3. Pinkish brown

What does decreased muscle tone do to bladder awareness?

Less aware of bladder fullness so experience incomplete emptying and excessive residual volume Kegal exercises help

Where it the uterus 6-12 hours after birth?

Level of umbilicus Descends 1 cm per day for 14 days

Postpartum Depression

Loss of interest in almost all activities Changes in appetite or weight, sleep, activity Decreased energy, Feelings of worthlessness or guilt Difficulty with focus and decision-making Recurrent thoughts of death or suicide

Lochia serosa

4-10 days, pink/brown

How long is bradycardia considered normal for?*

6 to 10 days

Scant lochia

< 2.5 cm

Why should a woman be cathed if experiencing PP hemorrhage?

A full bladder lifts the uterus, moving it up and to the side, preventing effective contraction of the uterine muscles

Which client data received during report should the nurse recognize as being a postpartum risk factor? A. Gravida 5, para 5 B. Labor duration of 4 hours C. Infant weight greater than 3800 g D. Epidural anesthesia for labor and birth

A. Gravida 5, para 5

The nurse notes that the fundus of a postpartum patient is boggy, shifted to the left of the midline, and 2 cm above the umbilicus. What is the nurse's priority action? A. Massage the fundus of the uterus. B. Assist the patient out of bed to void. C. Increase the infusion of oxytocin (Pitocin). D. Ask another nurse to bring in a straight catheter tray.

A. Massage the fundus of the uterus.

When can sexual activity resume?

After 6 weeks

Prevention of DVT PP*

Ambulate within first 6 hours

Treatment for superficial venous thrombosis

Analgesics, rest, elastic support, elevation to increase venous return, warm packs

Post-partum Blues- Clinical Manifestations

Anxious Moody Irritable Overwhelmed Fatigue Oversensitive Episodic tearfulness Lasts no longer than 2 wks

What should the nurse do if the uterine involution is too slow?*

Ask pt to void or cath them

Difference b/e PP blues and depression*

Blues lasts 2 wks, self-limiting, and does not affect ability to care for infant

What are major maternal concerns PP?

Body image and postpartum blues

Warning Signs to Report*

Bright red bleeding saturating more than one pad per hour or passing large clots Lochia alba/serosa back to rubra Odor Temp greater than 100.4 F

A postpartum client who is a gravida 4, para 4, comes to the office for her 6-week postpartum checkup. Her presentation is unkempt. She states that she is not sleeping well and feels overwhelmed at times. According to the client, family members' responses have been nonsupportive. What recommendations would you advise to help the client at this time?

Make appropriate referrals for psychological intervention counseling because the client is exhibiting high-risk symptoms

Subinvolution signs

Causes late PP hem delayed return of uterus to non-pregnant size Prolonged discharge of lochia Excessive uterine bleeding Pelvic pain/pelvic heaviness

Important teaching for new grandparents

Changes in baby care

Cervix postpartum

Closes to 2 to 3 cm after several days, admits a fingertip after 1 week Shape permanently changes after first delivery from round, dimple-like os to lateral slit-like os

How does retained placenta fragments cause late PP hem?

Clots form around the retained fragments, and excessive bleeding can occur when the clots slough away several days after delivery

Sign of lacteration

Continuous bleeding with firm fundus

Uterine involution

Contraction of the muscle fibers around the maternal blood vessels Decreased the size of the uterus Process takes 6-7 weeks

What 2 uterine atony meds cause diarrhea?

Cytotoc and hemabate

Predisposing factors of late PP

Manual removal of placenta Cord traction Placenta accreta Previous cesarean birth Uterine fibroids

Red or warm areas of breast indicate

Mastitis

Which instruction should be included in the discharge teaching plan to assist the client in recognizing early signs of complications? A. Palpate the fundus daily to ensure that it is soft. B. Report any decrease in the amount of brownish red lochia. C. The passage of clots as large as an orange can be expected. D. Notify the health care provider of any increase in the amount of lochia or a return to bright red bleeding.

D. Notify the health care provider of any increase in the amount of lochia or a return to bright red bleeding.

The nurse should expect medical intervention for subinvolution to include: A. oral fluids to 3000 mL/day. B. intravenous fluid and blood replacement. C. oxytocin intravenous infusion for 8 hours. D. oral methylergonovine maleate (Methergine) for 48 hours.

D. oral methylergonovine maleate (Methergine) for 48 hours.

What do stirrups increase the risk of?

DVT No more than 1 hour in stirrups and should be padded

Effect of low estrogen on vagina*

Decreased vaginal lubrication and vasocongestion for 6-10 weeks = dyspareunia

How does blood loss affect HCT?

Decreases HCT

Challenges to Family Adaptation

Discomfort and fatigue Increased household chores Feeling incompetent - lack of infant care experience Sleep deprivation Sense of lost freedom* Change in relationship roles Faulty expectation of newborn* Lack of support Personal temperament*

When is bonding time the most important?*

During 1st hour of life

Which phase is best for patient education?

During taking-hold phase

Nursing interventions for promoting attachment

Early, unlimited contact Prolonged contact & more touching More time to learn newborn's needs Assist parents to inspect the infant Position infant in an en face position Point out positive characteristics of infant "Mother the Mother"

Chills with fever indicates

Endometritis

How much fluid should be given?

Enough fluid should be given to maintain a urine flow of at least 30 mL/hr and preferably 60 mL/hr

How often should a woman be assessed for PP hemorrhage?

Every 15 minutes for first hour PP then tapered from there

What can help strengthen abdominal muscles PP?

Exercise!

4 degrees of lacerations

First degree- skin is torn Second degree- skin and the vaginal muscle is torn Third degree - through the anal sphincter Fourth - through the rectal mucosa

Signs of infection PP

Foul odor, pelvic or fundal pain, backache, and feelings of pelvic pressure or fullness

What is the first thing that should be done for PP hemorrhage?

Fundal massage

Important nursing intervention for a laceration*

Give IV fluids

Signs of worsening preeclampsia*

Headache, blurred vision, photophobia, proteinuria and abdominal pain

What uterine atony med cannot be given to pt with asthma?*

Hemabate

What does tachycardia PP indicate?*

Hemorrhage or infection

Which anticoagulats do not cross the placenta and can be given during pregnancy?

Heparin or Lovenox

What is there a risk of regarding thyroid levels?*

Hypothyroidism

What med can be given before breastfeeding to decrease discomfort?

Ibuprofen (motrin)

Important interventions for perineum

Icepack and peribottle Pat dry, do not wipe NSAIDS, narcotics

Why would a woman be more prone to incontinence after birth?*

If catheter is left inside while mom pushes leads to stress incontience

Why is increased fibrinogen for up to a week concerning?*

Increased risk for DVT/PE

How does losing extracellular fluid affect HCT?

Increases HCT

What fluids should be given during a hemorrhage?

Lactated Ringer's solution, whole blood, packed red blood cells, normal saline

Education for bottle feeding

Lactation suppression Good fitting bra and face away from shower to avoid stimulation

Predisposing factors for PP hemorrhage

Overdistention of the uterus (multiple gestation, large infant, hydramnios) Multiparity (five or more) Precipitate labor or delivery Prolonged labor Use of forceps or vacuum extractor Cesarean birth Manual removal of the placenta Placenta previa, placenta accreta, or low implantation Drugs: oxytocin, prostaglandins, tocolytics, or magnesium sulfate General anesthesia Chorioamnionitis Clotting disorders Previous postpartum hemorrhage or uterine surgery Disseminated intravascular coagulation Uterine leiomyomas (fibroids)

Meds to treat hemorrhage

Oxytocin IM Methergine IM Hemabate IM Cytotec rectally

SOB and chest pain indicates

PE

Bipolar II disorder

PPD imposter but wild swings of emotion May be unsafe with infant

What anxiety disorders can be PP?

Panic OCD PTSD

Taking-in phase

Passive, dependent, indecisive, Self-focused**** Needs To talk about birth, food, and rest

S/S hematomas

Pressure pain unrelieved by opioids

Attachment

Process of developing ties between parent and child Starts in pregnancy

What hormones control lactation?

Prolactin and oxytocin

Factors that slow uterine involution

Prolonged labor and difficult delivery* Anesthesia* Grand multiparity* Retained placental fragments or membranes Infection Overdistention of the uterus Full urinary bladder*

Bonding

Rapid initial attraction felt by parents

REEDA

Redness, edema, ecchymosis, discharge, and approximation

Letting- go phase

Relinquishes role as a childless couple Change of responsibilities Feelings of grief

What is placed before a C/S to prevent DVT?*

SCD

Heavy lochia

Saturated in 1 hour

How much lochia is considered excessive?*

Saturated pad in 1 hour

How much lochia is normal for first 24 hours PP?

Scant to moderate Should NOT be constant and steady

Management of hypovolemic shock

Second IV line - large bore (14—18 gauge) for IVF/Blood Increase iVF to maintain UO to 30 mL/hr Insert urinary catheter Vasopressors for hypotension Oxygen at 8 to 10 L/min via face mask Modified Trendelenburg to increase blood return from legs Draw labs - hemoglobin, hematocrit, coagulation studies, type & crossmatch

Meds for PPD

Selective serotonin reuptake inhibitors* Tricyclic antidepressants 4 weeks to become effective* Continue for 9-12 months after remission

When are headaches the most severe?

Sitting upright

Main cause of late PP hem

Subinvolution

What must a Bakri (Foley into uterus) be hooked up to?

Suction to prevent clots

Signs of hypovolemic shock

Tachycardia Hypotension Tachypnea Pale/cool skin Anxious, confusion, lethargy Decrease UO

Rubin's Process of Maternal Adaptation

Taking-in Taking-hold Letting-go

Signs of endometritis

Temperature of 38°C (100.4°F) or higher within 36 hours of birth, chills, malaise, anorexia, abdominal pain and cramping, uterine tenderness, foul-smelling lochia, tachycardia, and subinvolution

Why must clots be expressed if there is a postpartum hemorrhage?

They interfere with the ability of the uterus to contract effectively

Why should the woman be turned on her side during hemorrhage?

To detect more blood that cannot be visualized

Factors that Enhance Uterine Involution

Uncomplicated labor and delivery Breastfeeding Early ambulation Complete expulsion of placenta and membranes

Anticoagulation therapy during pregnancy lasts

Until labor begins It is resumed 6 -12 hours after birth and continued for 6 weeks to 6 months after birth

What is the major cause of uterine atony?*

Urinary retention

Nursing care of hypovolemic shock

VS Q3-5 min Assess Fundus, lochia amount, Skin temp, color, Capillary refill Administer oxygen Fluid bolus Monitor H&H, clotting Type & Cross Administer Blood, PRBCs, FFP Foley cath

What anticoagulant can NOT be givne during pregnancy?

Warfarin

What anticoagulant is given once PP?

Warfarin

How to measure blood loss

Weigh all blood-soaked items (e.g., peripads, linens). Weigh similar clean items. Subtract the weight of the dry items from that of the wet items. 1 g weight = 1 mL of blood.

When should perineal pain resolve after birth?

Within 2 weeks

Early PP hemorrhage

Within 24 hours

When should breastfeeding begin?*

Within first hour of life

Can PPD women have thoughts and feelings of wanting to harm the baby?*

Yes

Can SSRI be used while breast feeding?

Yes but under caution of doctor

Late PP hemorrhage

after initial 24 up to 12 weeks

Treatment of mastitis

antibiotics, continued breastfeeding/pumping, moist heat or ice packs, bed rest, fluids, analgesics

Treatment of DVT

bedrest, leg elevation, anticoagulants to prevent expansion of the thrombus (IV then SQ heparin), lab testing to determine response , analgesics, continuous moist heat, gradual ambulation

Why is a PP woman at a high risk for constipation?*

decreased peristalsis, use of narcotic analgesics and decreased mobility Stool by day 2 or 3

Treatment of PE

dissolve clot, oxygen 8-10 L/min, narcotic analgesics (decrease pain/anxiety), bed rest, increase HOB, IV heparin therapy

Signs of PE

dyspnea, chest pain, tachycardia, pulmonary rales, cough, hemoptysis, decreased oxygen saturation

Signs of UTI

dysuria, urgency, frequency, suprapubic pain, hematuria

Signs of Mastitis

flu-like with fatigue and aching muscle, temperature of 39°C (102.2°F) or higher, chills, malaise, and headache, localized lump/wedge shaped area of pain, redness, heat

Engrossment

have father spend time with baby in first 2 hours

Assessment of PP woman - BUBBLE - HE

o B- Breast o U- uterus o B- bladder o B- bowel o L- lochia o E- edema o H- hemorrhoids o E- emotions

Signs of DVT

pain in leg/groin, swelling in leg (>2cm larger than other leg), redness, heat

Diastasis recti

separation of rectus muscles of the abdomen

Homan's sign

sharp dorsiflexion is positive for DVT Plus red, tender, and warmth

Signs of superficial venous thrombosis

swelling, redness, tenderness, warmth Large, tender, sometimes palpable cordlike vein On calf

Uterine atony

the failure of uterus to contract around blood vessels when the placenta separates

Nursing interventions for endometritis

warm blankets, cool compresses, cold or warm drinks, or use of a heating pad, vitamin C and protein, oral fluids Abx