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