OB unit 5

nursing actions for the cardiovascular system

● Assess pulse and blood pressure: ● Every 15 minutes for the first hour after delivery. ● Every 30 minutes for the second hour. ● Every 4 hours for the next 22 hours. ● Every shift after the first 24 hours or as stated in hospital/unit protocols. ● Rationale: Hemodynamic changes occur during labor and delivery and in the postpartum period, including rapid changes in blood volume and cardiac output. Assessment of pulse and blood pressure is important to identify potential complications such as excessive blood loss, orthostatic hypotension, infection, and gestational hypertension/preeclampsia. An elevated pulse may indicate excessive blood loss, fever, or infection (James, 2014). ● Assess for excessive blood loss. Expected findings include: ● Pulse and blood pressure within normal ranges. However, after delivery there may be a transient 5% elevation in the woman's systolic and diastolic blood pressure (Isley & Katz, 2016). ● Bradycardia may occur postdelivery and in the early post-partum period, and is considered normal (James, 2014). ● Assess for orthostatic hypotension. Women are at risk for orthostatic hypotension during the first postpartum week when standing from a seated or prone position. ● Explain cause and incidence of orthostatic hypotension. ● Instruct the woman to rise slowly to a standing position. ● Assist the woman when ambulating during the first 24 hours postbirth. ● Assist the woman to a sitting position if she becomes dizzy or faint. ● Use an ammonia ampule if the woman faints. ● Check lab values such as a complete blood count (CBC), if ordered. ● Rationale: Components of the CBC, such as the hematocrit and hemoglobin, are assessed in cases where excessive blood loss has occurred. The hematocrit measures the concentration of red blood cells in the blood (Kee, 2009). Hemoglobin decreases by 1 to 1.5 g/dL and hematocrit decreases 3% to 4% per 500 mL of blood loss (James, 2014). ● Expected assessment findings: ● Blood loss within normal ranges ● Hemoglobin and hematocrit within normal ranges ● Anemia is not unusual during the postpartum period and is diagnosed if the hemoglobin is less than 11 g/dL and the hematocrit is less than 32%. Women may receive an oral iron supplement (ferrous sulfate) to treat postpartum anemia (Samuels, 2016). ● Pulse rate should be within normal limits; however, in some women bradycardia may occur. Blood pressure should be within normal limits. An increase in pulse rate may be an indicator of excessive blood loss or infection (James, 2014). Elevated blood pressure of 140/90 or greater may indicate preeclampsia (James, 2014). ● Assess lower extremities for venous thrombosis. ● Rationale: Increased coagulability associated with pregnancy continues into the postdelivery period. Additionally, venous stasis may occur when there is limited mobility in the immediate postpartum period. These factors lead to an increased risk of venous thrombosis (Isley & Katz, 2016). ● Assess the calves and the groin area for tenderness, edema, and sensation of warmth each shift. Compare pulses in both extremities. Measure the calf width if thromboembolism is suspected (James, 2014). ● Rationale: Symptoms of deep vein thrombosis include muscle pain; tenderness; palpation of a hard, cordlike vessel; swelling of veins; edema; and decreased blood circulation to the affected area. ● Expected assessment findings: ● No tenderness or sensation of warmth. ● Assess for postpartum chills. ● Assess temperature. ● Women who are experiencing chills with temperature within normal ranges may be offered a warm blanket and reassurance that it is normal. ● Women who are experiencing chills with elevated temperature should be evaluated further for possible infection, and the physician or midwife needs to be notified.

postpartum blues

symptoms disappear without medical intervention occurs within the first 6 weeks postpartum able to safely care for self and baby

Discharge Teaching and Health Promotion

•Nutrition: eat healthy, take in extra 500 cal •Permanent smoking cessation: give resources to keep it up •Physical activity and rest: get active and move around, not right away get the six week ok before like heavy working out and stuff •Family planning/Contraception: should start birth control when she plans to resume sex. Take it within the six week period so she will be protected when she resumes sex •Medication teaching:

Staging Obstetric/Hemorrhage and Medications for P P H

•Stage 1, 2, 3, 4 •Uterotonics •Oxytocin •Other medications Weigh pads and we have an under buttock drape that catches some blood Pg.421 Im going to put my pitocin in lactated ringers:10-40 units in 1000 mls of LR Pitocin - oxytocin Methergin: give 0.2 IM, don't give to someone with high BP Hemabate Cytotec Know the meds

lochia rubra

Days 1-3 Bloody with small clots Moderate to scant amount Increased flow on standing or breastfeeding Fleshy odor Large clots Heavy amount; saturates pad within 1 hour (sign of possible hemorrhage), excessively heavy, saturates a pad in 15 minutes Foul odor (sign of infection) Placental fragments

lochia serosa

Days 4-10 Pink or brown color Scant amount Increased flow during physical activity Fleshy odor Continuation of rubra stage after day 4 Heavy amount; saturates pad within 1 hour (sign of possible hemorrhage), excessively heavy; saturates pad within 15 minutes Foul odor (sign of infection)

HEMORRHAGE

Postpartum hemorrhage (PPH) is a blood loss greater than 500 mL for vaginal deliveries and greater than 1,000 mL for cesarean deliveries with a 10% drop in hemoglobin and/or hematocrit (Harvey & Dildy, 2012). Patients with PPH are treated using a two-pronged approach: (1) resuscitation and management of obstetric hemorrhage and potential hypovolemic shock and (2) identification and management of the underlying cause(s) of the hemorrhage.

Which of the following is the treatment of choice for primary postpartum hemorrhage? A. Terbutaline B. Oxytocin C. Misoprostol D. Low-weight heparin

B Oxytocin is the treatment of choice for primary postpartum hemorrhage

Endometrial changes are assessed by examining which of the following? A. Vital signs B. Lochia C. Fundal height D. All of the above

B The appearance and amount of lochia tells the nurse about the progress of endometrial shedding and regeneration. The lochia tells what the situation is going on in the endometrium and the endometrial lining

lochia alba

Day 10 Yellow to white in color Scant amount Fleshy odor Bright red bleeding, saturates pad within 1 hour (sign of possible late postpartum hemorrhage) Foul odor (sign of infection)

endometritis from the book

Endometritis, also referred to as metritis, is an infection of the endometrium, myometrium, and/or parametrial tissue that usually starts at the placental site and spreads to encompass the entire endometrium. Approximately 2% of women who experience a vaginal birth and 15% of women who experience a cesarean birth develop endometritis. The uterine cavity is usually sterile until the rupture of the amniotic sac. As a consequence of labor, delivery, and associated manipulations, anaerobic and aerobic bacteria can contaminate the uterus. Endometritis is an infection of the uterus characterized by postpartum fever, midline lower abdominal pain, and uterine tenderness. Also, purulent lochia, chills, headache, malaise, and/or anorexia may be present.

stage 4 of ob hemorrhage

Hemorrhage: Cardiovascular collapse (massive hemorrhage, profound hypovolemic shock, or amniotic fluid embolism) Initial Steps Mobilize additional resources Medications ACLS Blood Bank Simultaneous aggressive massive transfusion Action Immediate surgical intervention to ensure hemostasis (hysterectomy)

stage 3 of ob hemorrhage

Hemorrhage: Continued bleeding with EBL >1,500 mL OR >2 units RBCs given OR patient at risk for occult bleeding/coagulopathy OR any patient with abnormal vital signs/labs/oliguria Initial Steps Mobilize additional help Move to operating room Announce clinical status (vital signs, cumulative blood loss, etiology) Outline and communicate plan Medications Continue Stage 1 medications Blood Bank Initiate massive transfusion protocol (if clinical coagulopathy, add cryoprecipitate, consult for additional agents) Action Achieve hemostasis, interventions based on etiology

SAFE AND EFFECTIVE NURSING CARE: Understanding Medication RhoGam

Rho immune globulin is given to Rh-negative women at 28 weeks' gestation. Rh-negative women who gave birth to an Rh-positive neonate are screened for anti-Rh antibodies (Coombs' test). A second injection of Rho immune globulin is given to the woman in the postpartum period if her baby is Rh positive and she is Coombs' negative. Medication Rh (D) Immune Globulin (RhoGAM, Rhophylac) ● Indication: Administered to Rh-negative women who have given birth to an Rh-positive neonate ● Action: Prevents production of anti-Rh (D) antibodies ● Adverse reactions: Pain at the injection site, anemia, allergic reaction ● Route and dose: 300 mcg Rhogam IM only, or Rhophylac, 300 mcg IV or IM within 72 hours postbirth ● Nursing actions: Confirm that the mother is Rh negative and the infant is Rh positive prior to administration. Observe patient for 20 minutes after administration for signs of an allergic reaction. Rh immune globulin may interfere with the immune response to live vaccinations (e.g., measles, mumps, rubella [MMR]). The administration of live vaccines should be delayed for 3 months following administration.

endometritis from the book x2

Risk Factors ● Cesarean birth is a primary risk factor ● Prolonged rupture of membranes ● Prolonged labor ● Internal fetal and uterine monitoring ● Meconium-stained fluid ● Multiple cervical exams during labor ● Obesity Assessment Findings ● Elevated temperature greater than 100.4°F (38°C) with or without chills ● Midline lower abdominal pain or discomfort ● Uterine tenderness ● Tachycardia ● Subinvolution ● Malaise ● Headache ● Chills ● Lochia heavy and foul-smelling when anaerobic organisms are present ● Foul-smelling lochia is a later sign that occurs when the entire endometrium is involved. ● Lochia is scant and odorless when beta-hemolytic streptococcus is present. Medical Management Endometritis is usually treated with broad-spectrum IV antibiotics and rest. Blood cultures to identify the causative organism of endometritis are done if the patient does not respond to empiric therapy. White blood cell (WBC) counts are monitored. ● CBC to assess for leukocytosis (WBC count greater than 20,000/mm3) ● Endometrial cultures ● Blood cultures ● Urinalysis to rule out urinary tract infection, which can present with similar symptoms ● Antibiotic therapy ● Mild cases: Oral antibiotic therapy ● Moderate to severe cases: IV antibiotic therapy, which is discontinued after the woman is afebrile for 24 hours. ● Improvement should be noted within 72 hours of initiation of antibiotic therapy. Nursing Actions ● Reduce risk of endometritis. ● Educate the woman regarding proper hand-washing techniques to reduce spread of bacteria. ● Instruct the woman in proper pericare and to wipe perinium front to back. ● Instruct the woman to change her peripad every 3 to 4 hours or sooner because lochia is a medium for bacterial growth. ● Encourage early ambulation by explaining how ambulation reduces the risk of infection by promoting uterine drainage. ● Encourage intake of fluids to rehydrate by explaining to the woman that maintaining adequate hydration can reduce her risk for infections. Woman should have a minimum fluid intake of 3,000 mL/day (James, 2014). ● Educate the woman on a diet high in protein and vitamin C, which aids in tissue healing. ● Monitor WBC count. However, it is important to remember that this is normally elevated after delivery for a short period; continued monitoring of the WBC count is required in identifying endometritis and is likely to show a left shift and increasing number of neutrophils. ● Monitor for signs and symptoms of endometritis. ● Report assessment data of possible endometritis and abnormal laboratory reports to physician and/or midwife for further evaluation. ● Administer antibiotics as ordered. ● Provide pain management measures. ● Provide emotional support to the woman and her family. ● Discharge teaching ● Provide information on discharge medications. ● Provide information on signs and symptoms to report to health care provider.

trauma: lacerations

• Firm uterus with continued bleeding • Steady trickle of unclotted, bright red blood • Call provider to evaluate, locate, and repair laceration • Monitor vital signs and lochia • Weigh pads and chux to monitor blood loss

Postpartum Hemorrhage

•Maternal morbidity and mortality: how we loose most of our moms nation wide, prevent it as all possible •Treat hypovolemic shock and underlying causes •Quantification of blood loss •Threshold parameters

causes of pph

•Tone: is uterus toning up? •Tissue: damage to the tissue?, retained placental fragments? If so she will continue to bleed •Trauma: as baby is coming through: any cut or hematoma Thrombin disorders: diseases that would lead to hemorrhage of mom (DIC

Smoking Cessation and Relapse Prevention

● Ask women about tobacco use. ● Teach women about the dangers of smoking (e.g., cancer, lung problems such as chronic obstructive pulmonary disease, osteoporosis). ● Teach women to never allow smoking around their infant/children, as secondhand smoke is associated with problems such as ear infections and respiratory issues. ● Encourage women who quit smoking for pregnancy to remain abstinent. Most women who quit smoking during pregnancy relapse after delivery. ● Advise women who currently smoke to quit. Provide information about resources to assist with cessation, such as counseling services/classes, cessation help lines, and medications.

Vagina and Perineum

● The vagina and perineum experience changes related to the birthing process that may include edema, mild stretching, minor lacerations, major tears, and/or episiotomies. ● A first-degree laceration involves the vaginal mucous membranes and the perineal skin. ● A second-degree laceration involves the vaginal mucous membranes, perineal skin, and the fascia of the perineal body. ● A third-degree laceration involves the perineal skin, vaginal mucous membranes, fascia of the perineal body, and the rectal sphincter. ● A fourth-degree laceration involves the perineal skin and fascia, vaginal mucous membranes, rectal sphincter, and the rectal mucosa and lumen. ● A midline episiotomy is an incision that is midline on the perineum. This type of incision tends to heal more quickly and cause less pain then a mediolateral episiotomy. ● A mediolateral episiotomy is an incision that is made at a 45-degree angle to the perineum. See Chapter 8 for further discussion of lacerations and episiotomy. The woman may experience mild to severe pain, depending on the degree and type of vaginal and/or perineal trauma. Women who have a third- or fourth-degree laceration, an episiotomy, or hemorrhoids may require a stool softener or laxative to facilitate bowel movements (Isley & Katz, 2016). The primary complication is infection at the laceration or episiotomy site. Lacerations can tear posteriorly toward the rectum, causing difficulty with bowel movements. Lacerations can also tear anteriorly toward the urethra, causing swelling and possibly difficulty with urination. The vagina and perineum undergo healing and restoration during the postpartum period. Immediately after delivery, the vaginal walls are smooth, but rugae are reestablished within 3 weeks of delivery (James, 2014).

The Immune System from notes

-Postpartum vaccinations: might want to give them these while you have them captive -R h-sensitization: if you don't know the babies type or moms type just give it anyway Mmr for rubella: measles, mumps, rubella Know about rhogam When a RH - women gives birth to a ph+ baby there is a chance that some antibodies are forming, and it will harm the next fetus -if mom and baby are rh- you don't have any issues. But if the mom is negative and baby is positive then we can have a problem -RhoGAM prevents her from forming those antibodies : within 72 hours after birth, given even if we don't know the blood type -if mom has an abortion, we given RhoGAM

cystitis

Cystitis is a bladder inflammation/infection. ● Symptoms: Frequency, urgency, pain/burning on urination, suprapubic tenderness, hematuria, and malaise ● Treatment: Antibiotic therapy, increased hydration, rest

Gastrointestinal postpartum changes include which of the following? A. Constipation B. Hemorrhoids C. Increased appetite D. All of the above

D After delivery the mother may experience constipation, hemorrhoids, and increased appetite.

Overview of the Postpartum Assessment

The following should be assessed per the health care provider's order or unit protocol. ● Vital signs, pain, breath and heart sounds ● Laboratory findings, such as CBC, rubella status, and Rh status ● Breasts ● Uterus ● Bladder ● Bowel ● Lochia ● Episiotomy, lacerations, perineum, hemorrhoids ● Lower extremities ● Emotions, bonding with infant, fatigue, psychosocial factors

wound infections

can occur at the laceration site, episiotomy site, and cesarean incision site. Aseptic technique throughout childbirth and postpartum is critical in decreasing the woman's risk for wound infections. Most often, the etiologic organisms associated with perineal cellulitis and episiotomy site infections are Staphylococcus or Streptococcus species and gram-negative organisms, as in endometritis. Postpartum patients with wound infections typically have wounds that exhibit redness, warmth, poor wound approximation, tenderness, and pain. If untreated, these patients may develop a fever and other symptoms of an infection, such as malaise. Blood cultures may be obtained to isolate the causative organism. Antibiotics will typically be administered, and drainage of the wound may be necessary. Patients must be taught about proper hand washing and encouraged to maintain adequate fluid intake and increased protein intake to assist in wound healing. Wound infections can be intensely painful, especially in the perineum. Therefore, the nurse assists these patients in managing pain with analgesics and positioning.

PPD

requires psychiatric interventions occurs within the first 12 months postpartum unable to safely care for self and/or baby

Tone (uterine atony)

• Large baby • High parity • Rapid labor • Fever • Fibroids • Bleeding may be slow and steady, or profuse • Large, boggy uterus • Clots • Assist the uterus to contract via massage and/or medications • Monitor bleeding—weigh pads and chux (1 gm = 1 mL) • Maintain fluid balance (may need second IV, Foley catheter) • Monitor vital signs and labs; blood type and screen if ordered • Administer oxygen 10-12 L via face mask • Keep patient warm

The Gastrointestinal System

•Constipation and hemorrhoids •Appetite increases •Encourage fluids and food •Nursing assessment and actions Prevent constipation: high fiber

THE URINARY SYSTEM

•Risk of urinary complications postpartum •Bladder distention •Cystitis risk; bathroom every 2-4 hours, we want 300c within 2-4 hours after delivery. If less they may need to scan her and see for retention •Nursing assessment and actions Bladder could only hold a little bit during those last few days of labor The urine stasis from an epidural will lead to an UTI: dysuria, urgency, frequency, fever, increased WBC, may need a UA, give a general ABX first then get more specific If mom cant use the bathroom within 6 hours after birth we will do a straight catheter

Patient Education for breastfeeding woman

● Instruct the woman to wear a supportive bra or sports bra 24 hours a day until her breasts become soft. Teach the woman to avoid expressing milk or stimulating the breasts. ● Rationale: Atrophy in milk-secreting cells of the breasts can be caused by back pressure in the milk ducts that occurs when the breasts are not emptied (Janke, 2014). ● Instruct the woman who is experiencing engorgement to: ● Apply ice to the breasts. ● Not express milk because this stimulates milk production. ● Avoid heat to the breast because this can stimulate milk production. ● Take an analgesic for pain. ● Document findings and interventions.

THE MUSCULAR AND NERVOUS SYSTEMS from the book

After birth, the abdominal muscles experience reduced tone and the abdomen appears soft and flabby. Some women experience a separation of the rectus muscle, which is no ted as diastasis recti abdominis (Fig.12-4). This separation becomes less apparent as the body returns to a prepregnant state. Women may experience muscular soreness related to the labor and birth experience. Lower body nerve sensation may be diminished for women who have received an epidural during labor. Delay ambulation until full sensation returns.

more notes on the causes of pph

Ask if they have a blood disorder? In a c-section delivery we want no more than a 1000cc of blood loss and no more than a 10% drop in hgb Post partum risk assessment: -do that on the L&D unit on admission and when necessary (post partum unit) -do you have a blood disorder (factor 8/vonrelbrans)

Pregestational Diabetes

Insulin requirements for the pregestational diabetic woman decrease in the immediate postpartum period. With oral intake, subcutaneous insulin doses can resume, typically at prepregnancy normal glucose tolerance postpartum doses (Daley, 2014). Women with diabetes are at higher risk for complications such as infection and should be closely monitored for mastitis, endometritis, and wound infections. Breastfeeding is highly encouraged. Benefits include a reduction in the risk of developing type 2 diabetes mellitus (T2DM) for women with gestational diabetes mellitus (GDM), especially with exclusive breastfeeding (avoid formula supplementation) and longer duration of lactation. Utilization of 500 kcal per day for lactation may lead to improved pregnancy weight loss.

POSTPARTUM FOLLOW-UP

POSTPARTUM FOLLOW-UP At discharge from maternity care, the woman should receive contact information for her postpartum care team and written instructions regarding the timing of follow-up postpartum care. Women are recommended to have a comprehensive postpartum visit within the first 6 weeks after birth. This visit will include a full assessment of physical, social, and psychological well-being and a discussion of the desired form of contraception. At the conclusion of the postpartum visit, the woman and her provider determine who will assume primary responsibility for her ongoing care. If responsibility is transferred to another primary care provider, the obstetric care provider is responsible for ensuring that there is communication with the primary care provider so that he or she can understand the implications of any pregnancy complications for the woman's future health and maintain continuity of care. Postpartum patients and their families are instructed to call the health care provider if the woman experiences any of the following: ● Fever ● Foul-smelling lochia ● Large blood clots (golf ball-sized or bigger) or bleeding that saturates a pad in 1 hour ● Discharge, erythema, or severe pain from incisions or stitched areas ● Hot, red, painful areas on the breasts or legs ● Bleeding and/or severe pain in the nipples or breasts ● Severe headaches and/or blurred vision ● Chest pain and/or dyspnea without exertion ● Frequent, painful urination ● Signs of depression

CRITICAL COMPONENT Uterine Atony (Boggy Uterus)

Uterine atony is the most common cause of postpartum hemorrhage. Because hemostasis associated with placental separation depends on myometrial contraction, atony is treated initially by uterine massage, followed by drugs that promote uterine contraction. • A boggy uterus is a sign that the uterus is not contracted. • Risk of excessive blood loss and/or hemorrhage is increased. • The immediate action is to massage the fundus with the palm of your hand in a circular motion until firm and reevaluate within 5 to 10 minutes. • If the uterus does not respond to massage, follow the standing order for oxytocin and notify the physician or midwife.

the urinary system from the book

Women are at risk for urinary complications after birth. Transient stress incontinence associated with impaired pelvic muscle function involving the urethra may occur in the first 6 weeks postpartum (Isley & Katz, 2014; James, 2014). Many factors are associated with stress urinary incontinence, including pregnancy, multiparity, perineal trauma, infant size, length of second stage labor, and pushing techniques that increase pressure on the pelvic floor (James, 2014). Primary complications are bladder distention and cystitis.

tissue

• Retained or abnormal placenta • In addition to the above, uterus may not respond to interventions • Uterus may remain larger than normal • Strings of tissue may be seen in the blood • Call provider to assess; D&C may be needed • Monitor for signs of shock • Administer oxygen if indicated

Nursing Actions for the Nonbreastfeeding Woman

● Assess the breasts for primary engorgement. ● Inspect and palpate the breasts for signs of engorgement: tenderness, firmness, warmth, and/or enlargement. ● Rationale: In women who choose not to breastfeed, milk leakage, breast pain, and engorgement may be experienced between 1 and 4 days postdelivery (James, 2014). ● Expected assessment findings: ● During the first 24 hours postpartum, the breasts are soft and nontender. ● On postpartum day 2, the breasts are slightly firm and nontender. ● On postpartum day 3, the breasts are firm and tender.

nursing actions for uterine assessment

● Assess the uterus for location, position, and tone of the fundus. ● After the third stage of labor, assess the uterus: ● Every 15 minutes for the first hour. ● Every 30 minutes for the second hour. ● Every 4 hours for the next 22 hours. ● Every shift after the first 24 hours or as stated in hospital/unit protocols. ● More frequently if the assessment findings are not within normal limits. ● Frequent assessment of uterine tone and placement allows for the identification of potential complications such as uterine atony (decreased uterine muscle tone) that may lead to postpartum hemorrhage (Cunningham et al., 2014). ● The risk for postpartum hemorrhage is the greatest within the first hour following delivery (Cunningham et al., 2014). ● Primary (early) postpartum hemorrhage occurs during the first 24 hours after birth. ● Secondary (late) postpartum hemorrhage may occur from 24 hours to 12 weeks postdelivery but is most prevalent during the first 7 to 14 days following birth (Cunningham et al., 2014). ● See Chapter 14 for more information about the care of the woman with postpartum hemorrhage. ● Before assessment, inform the woman that you will be palpating her uterus to evaluate for normal involution and bleeding. ● Explain the procedure. ● Instruct the woman to void. ● Rationale: An over-distended bladder can result in uterine displacement and atony (James, 2014). Encouraging the woman to void prior to uterine assessment will allow for an accurate assessment of uterine placement and tone. ● Provide privacy. ● Lower the head and foot of the bed so that the woman is in a supine position and flat. ● Remove her peripads to evaluate lochia at the same time the fundus is palpated. ● Support the lower uterine segment by placing one hand just above the symphysis pubis (Fig. 12-1). ● Rationale: Pregnancy stretches the ligaments that hold the uterus in place. Fundal pressure could result in uterine inversion (James, 2014). Supporting the lower uterine segment may prevent uterine inversion during fundal assessment or massage. FIGURE 12-1 Nurse supporting lower uterine segment while assessing the postpartum uterus. ● Locate the fundus with the other hand using gentle downward pressure and assess the position, tone, and location of the fundus. ● The fundus may be firm (contracted) or soft (boggy) in tone. ● A boggy uterus indicates that the uterus is not contracting and places the woman at risk for excessive blood loss. If the uterus is boggy, the nurse should: ● Massage the fundus with the palm of the hand, as fundal massage stimulates contraction of the uterus (Smith, 2018). ● Rationale: Fundal massage stimulates contraction of the uterus (Smith, 2018). ● Give oxytocin as per the physician's or midwife's post-partum orders. ● Rationale: Oxytocin promotes contraction of the uterus by stimulating its smooth muscle, which prevents and controls postpartum hemorrhage (Wilson et al., 2014). ● Notify the physician or midwife if the uterus does not respond to massage and postpartum orders have been implemented. ● Lack of response to fundal massage and oxytocin administration may indicate complications such as retained placental tissue or birth trauma (Hobel & Lamb, 2016). Continued uterine atony can lead to postpartum hemorrhage and requires assessment and potentially further treatment by the woman's health care provider. ● Measure the distance between the fundus and umbilicus with your fingers. Each finger breadth equals 1 cm. ● Determine the position of the uterus. ● Rationale: A uterus that is shifted to the side may indicate a distended bladder. This interferes with uterine contractibility, which places the woman at risk for uterine atony and increases her risk of hemorrhage (James, 2014). ● If the uterus is deviated, soft, or elevated above the umbilicus, the immediate action is to explain to the patient the need for her to void and to assist her to the bathroom. Reassess the uterine position after the woman has voided and returned to her bed. If the patient is unable to void, urinary catheterization may be necessary. ● Immediately after birth, the uterine fundus is palpated midway between the umbilicus and symphysis pubis and is firm and midline. In the next few hours it is palpated at the umbilicus. ● Within 12 hours after birth of the placenta, the fundus is located at the level of the umbilicus or 1 cm above the umbilicus and is firm and midline. ● 24 hours after birth of placenta, the fundus is located at 1 cm below the umbilicus and is firm and midline. ● The uterus descends 1 cm per day; by day 14 the fundus has descended into the pelvis and is not palpable. ● Subinvolution is the failure of the uterus to involute/descend as expected. Causes include retained placental fragments, infection, and over-distended uterus (e.g., from a large baby). Subinvolution may lead to prolonged or excessive bleeding during the postpartum period (Cunningham et al., 2014). The nurse should also provide information regarding afterpains, uterine cramps caused by the contraction, and relaxation of the uterus as it decreases in size. ● Afterpains occur within the first few days and typically decrease 3 days after delivery. ● They occur more commonly with multiparous women and increase with each additional pregnancy/birth. ● The condition may increase when breastfeeding during the first few postpartum days. ● Comfort measures include the following: ● Encourage patient to empty bladder, as a distended bladder can increase afterpains. ● Apply warm blanket to abdomen. ● Relaxation techniques and warm compresses can interfere with the transmission and sensation of pain. ● Analgesics such as ibuprofen are effective in relieving uterine cramping

Nursing Actions for the Breastfeeding Woman

● Inspect and palpate the breasts for signs of engorgement: tenderness, firmness, warmth, and/or enlargement. ● Expected assessment findings: ● During the first 24 hours postpartum, the breasts are soft and nontender. ● On postpartum day 2, the breasts are slightly firm and nontender. ● On postpartum day 3, the breasts are firm, tender, and warm to touch. ● Assess the nipples for signs of irritation and nipple tissue breakdown. ● Rationale: Signs of irritation and tissue breakdown are cracked, blistered, or reddened areas. Skin breakdown of the nipples is often associated with an improper infant latch. Nipple soreness is a primary reason that women stop breastfeeding, so this complaint should be addressed (Janke, 2014). Additionally, skin breakdown can be an entry point for bacteria (Cunningham et al., 2014). See Chapter 16 for interventions to prevent/treat nipple irritation and breakdown. ● Assess for plugged milk ducts

nursing actions for the vagina and perineum

● The perineum is assessed when the fundus and lochia are checked in the postdelivery period (James, 2014). After that, the perineum is assessed every shift using the acronym REEDA (redness, edema, ecchymosis, discharge, approximation of edges of episiotomy or laceration). ● Rationale: Frequent assessment of the perineum using the REEDA scale will allow identification of potential complications, such as excessive swelling, infection, hematoma, and excess bleeding (James, 2014). See Chapter 14 for more information about lacerations and hematoma. ● Explain the procedure. ● Provide privacy. ● Lower the head and foot of the bed so that the woman is in a supine position and flat. ● Remove her peripads to evaluate labia and perineum anteriorly. ● Assist the woman to her side and separate the buttocks to expose the perineum and rectum for assessment. ● Rationale: Assess the perineum anteriorly, then place the woman in the side-lying position to inspect the perineal area and assess the amount of lochia present on the entire peripad. While the woman is in the side-lying position, assess the rectal area for hemorrhoids. ● Expected assessment findings: ● Mild edema ● Minor ecchymosis ● Approximation of the edges of the episiotomy or laceration if visible; most lacerations are internal and not visible. ● Mild to moderate pain ● Assess for discomfort and provide comfort measures. ● Apply ice to the perineum, or encourage the use of cold sitz baths for the first 24 to 48 hours to manage swelling (East et al., 2012). ● Rationale: Ice causes local vasoconstriction, which decreases edema and provides an anesthetic effect (Cunningham et al., 2014; Isley & Katz, 2016). ● Encourage the woman to lie on her side. ● Rationale: The side-lying position decreases pressure on the perineum. ● Instruct the woman to tighten her gluteal muscles as she sits down and to relax muscles after she is seated. ● Rationale: This helps cushion the perineum and increases comfort when assuming a sitting position. ● Instruct the woman to wear peripads snugly to prevent rubbing. ● Instruct the woman to take warm sitz baths, starting 24 hours after delivery twice a day for 20 minutes. ● Rationale: Warm sitz baths promote circulation, healing, and comfort (Cunningham et al., 2014). ● Administer a topical anesthetic per the physician's or midwife's order. ● Rationale: Topical anesthetics may relieve localized discomfort (Cunningham et al., 2014). ● Administer analgesia per the physician's or midwife's order and assess adequacy of pain relief within 30 minutes. Note the patient's acceptable pain level, as sometimes we cannot achieve 0 pain. Analgesics such as ibuprofen are effective in treating perineal pain (Isley & Katz, 2016). ● Reduce the risk for infection. ● Instruct the woman to use a peri-bottle with warm water and rinse the perineum after elimination. ● Instruct the woman to change the peripad frequently. ● Instruct the woman to properly dispose of soiled pads and to wash her hands. ● Rationale: Lochia is a medium for bacterial growth. Frequent pad changes and hand washing will reduce the risk for infection.

bladder distention

Bladder distention, rapid bladder filling, incomplete emptying, and inability to void are common during the first few days postbirth (Cunningham et al., 2014). These are related to administration of intravenous fluids in the postdelivery period, decreased sensation of the urge to void due to anesthesia or analgesia, edema around the urethra, perineal lacerations or episiotomy, operative vaginal delivery, or bladder trauma (Cunningham et al., 2014; Mulder, Oude Rengerink, Van der Post, Hakvoort, & Roovers, 2016). Diuresis caused by decreased estrogen levels occurs within 12 hours after birth and aids in the elimination of excess tissue fluids. During this time urine output may be 3,000 cc or more per day

THE RESPIRATORY SYSTEM

Chest wall compliance returns after the birth of the infant as diaphragm pressure is reduced. The respiratory system returns to a prepregnant state by the end of the postpartum period. Nursing Actions ● Assess the respiratory rate: ● Every 15 minutes for the first hour. ● Every 30 minutes for the second hour. ● Every 4 hours for the next 22 hours. ● Every shift after the first 24 hours or as stated in hospital/unit protocols. ● Assess breath sounds. ● Rationale: Women who received oxytocin, large amounts of intravenous fluids, or tocolytics such as magnesium sulfate or terbutaline; had multiple birth, infection, or preeclampsia; or who were on bed rest are at risk for pulmonary edema (James, 2014). ● Expected assessment findings: ● Within normal limits. The respiratory rate in the postpartum period is typically in the range of 12 to 20 breaths per minute (bpm). The Pao2 should be 95% or higher (James, 2014). ● Breath sounds clear. ● Document findings and intervention.

Diaphoresis

Diaphoresis occurs during the first few postpartum weeks in response to decreased estrogen levels. This profuse sweating, which often occurs at night, assists the body in excreting the increased fluid accumulated during pregnancy. Nursing Actions ● Assess for diaphoresis. ● If present, assess for infection by taking the woman's temperature. ● Expected assessment findings: ● Diaphoresis with temperature within normal ranges Patient Education ● Instruct the woman regarding the cause of diaphoresis. ● Discuss comfort measures such as wearing cotton nightwear. ● Discuss that feelings of warmth, sweating, and chills are signs of fever, a cardinal sign of infection. Women with these symptoms need to differentiate between fever and diaphoresis, the latter of which is a normal physiological process. ● Document findings and interventions.

stage 1 of ob hemorrhage

Hemorrhage: Blood loss >500 mL vaginal OR blood loss >1,000 mL cesarean with normal vital signs and lab values Initial Steps Ensure 16G or 18G IV access Increase IV fluid (crystalloid without oxytocin) Insert indwelling urinary catheter Fundal massage Medications Increase oxytocin, additional uterotonics Oxytocin (Pitocin), 10-40 units per 500-1,000 mL solution Methylergonovine (Methergine), 0.2 mg IM (may repeat) 15-methyl PGF2α (Hemabate, Carboprost), 250 mcg IM (may repeat in q15 minutes, maximum 8 doses) Misoprostol (Cytotec), 800-1,000 mcg PR 600 mcg PO or 800 mcg PL Blood Bank Type & cross-match 2 units RBCs Action Determine etiology and treat. Consider 4 Ts—tone (i.e., atony), trauma (i.e., laceration), tissue (i.e., retained products), and thrombin (i.e., coagulation dysfunction) Prepare operating room, if clinically indicated (optimize visualization/examination)

more notes on introduction of post partum physiologic assessments and nursign care

Infection can come from the placental detachment site as well as the c-section incision site Postpartum period is the 6-week period after childbirth Our goal is that we have the best health outcome for mom and make sure that she has all the education she needs -how to ask for pain meds, how to assess her own pain and stuff like that Nursing outcomes: -recovery: want her to recover well, we want to give great discharge teaching that will optimize baby and moms health. Teaching self care

patient education for the endometrium

● Teach the woman how to assess the fundus and explain the normal process of involution. ● Teach the woman how to massage her uterus if boggy and instruct her to notify the nurse while in the hospital and health care provider after discharge. ● Rationale: Secondary hemorrhage often occurs after the patient has been discharged. To prevent serious complications, women should understand the normal progression of lochia and uterine involution, and report abnormal amounts of bleeding. ● Provide information on the normal stages of lochia. ● Explain that the flow of lochia can increase when getting up in the morning or after sitting for prolonged periods of time due to vaginal pooling of lochia or from excessive physical activity. ● Instruct the woman to notify the nurse, physician, or midwife if she experiences an increase in the amount of lochia, if the color of lochia changes back to bright red after the rubra stage is over, or if the lochia has a foul odor. ● Rationale: Lochia should decrease in amount every day. Foul-smelling lochia could indicate the development of an infection. An increase in lochia or the return of bright red bleeding may be signs of secondary hemorrhage (Cunningham et al., 2014). ● Provide information for reducing the risk of infection such as instructing the patient to change the peripad frequently from the front to back, wash hands before and after changing pads, and use a peri-bottle to keep the area clean. ● Rationale: Lochia is a medium for bacterial growth. Frequent pad changes and hand washing are actions aimed at preventing infection. ● Document the stage amount and odor of lochia and interventions.

Contraception

● Assess the couple's desire for future pregnancies. ● Assess satisfaction with previous method of contraception. ● Encourage the patient to discuss contraceptive options with the health care provider. The immediate placement of long-acting reversible contraception (LARC), such as intrauterine devices and contraceptive implants, is an option during the postpartum period (ACOG, 2016). LARC is highly effective in preventing unwanted pregnancy and short intervals between pregnancies (ACOG, 2016). ● Provide information on various methods of contraception

Patient Education on the cardiovascular system

● Instruct the woman on ways to reduce risk of orthostatic hypotension. Women should be accompanied by the nurse during ambulation in the early postpartum period. ● Rationale: Orthostatic hypotension places the patient at risk for fainting and falls. ● Encourage frequent ambulation. ● Rationale: Early and frequent ambulation prevents deep vein thrombosis by preventing stasis of blood in the lower extremities (Cunningham et al., 2014). ● Instruct the woman not to cross her legs (James, 2014). ● Apply compression stockings per provider orders for women with a history of blood clots

risk factors for pph

● Neonatal macrosomia: birth weight greater than 4,000 g ● Placenta previa or placenta accreta ● Multiple gestation ● Previous cesarean or uterine surgery ● Polyhydramnios ● High parity ● Prior PPH ● Operative vaginal delivery: use of forceps or vacuum extractor ● Augmented or induced labor ● Ineffective uterine contractions during labor: prolonged first and second stage of labor ● Precipitous labor and/or birth ● Chorioamnionitis ● Maternal obesity ● Congenital or acquired coagulation defects

Rest and Comfort

● Teach the woman the importance of rest in promoting healing and lactation. ● Problem-solve with the woman about ways to increase rest time (e.g., nap when the baby is napping, prioritize activities). ● Encourage the woman to take medications as ordered by the physician or midwife (e.g., vitamins, iron, pain medications).

introduction of post partum physiologic assessments and nursign care

-Postpartum adaptation -Optimizing maternal health and education -Nursing diagnoses: pain, risk for infection, balanced fluid volume, adjusting to motherhood -Nursing outcomes: recovery, health promotion, pain management, self-care, increased knowledge

THE ENDOCRINE SYSTEM from the book

Abrupt changes occur in the endocrine system after the delivery of the placenta. Estrogen, progesterone, and prolactin levels decrease. Estrogen levels begin to rise after the first week post-partum. For nonlactating women, prolactin levels continue to decline throughout the first 3 postpartum weeks. Menses begins 7 to 9 weeks postbirth. The first menses is usually anovulatory. Ovulation usually occurs by the fourth cycle. The average time for women who are not breastfeeding to return to ovulation is 10 weeks postpartum (James, 2014). In women who are lactating, prolactin levels increase in response to the infant's suckling. Lactation suppresses menses, likely due to hormonal changes, including elevated prolactin levels (James, 2014). Return of menses depends on the length and amount of breastfeeding. Ovulation is suppressed longer for lactating women than for nonlactating women. The mean time to return to ovulation for women who breastfeed is 17 weeks postdelivery (James, 2014). Both lactating and nonlactating women should be advised to use contraception when they resume sexual intercourse, as ovulation can precede return of menses. Breastfeeding is not an effective contraceptive method.

Breast Care and Assessment

Common findings include: ● Breast engorgement: caused by an increase in the vascular and the lymphatic systems within the breast and milk accumulation. ● Physiological engorgement: ● Breasts are swollen. ● Pathological engorgement: ● Breasts are hard, swollen, red, and tender/painful. ● Breasts feel warm to the touch. ● Woman may feel a throbbing sensation in the breasts. ● Woman may have an elevated temperature. ● Infant may have difficulty latching on due to the severe engorgement (Newton, 2016). ● Treatment for breastfeeding women: ● Frequent feedings to empty the breasts and to prevent milk stasis ● Warm compresses to the breast and breast massage to facilitate the flow of milk prior to feeding sessions ● Express milk by breast pump or manually if the infant is unable to nurse (i.e., preterm infant) ● Ice packs after feedings to reduce inflammation and discomfort ● Analgesics for pain management ● Wear a supportive bra ● Prevention and treatment for nonbreastfeeding women ● Wear a supportive bra ● Avoid stimulating the breast ● Ice packs to breast ● Analgesics for pain management ● Subsides within 48 to 72 hours (Janke, 2014) ● Plugged milk ducts are associated with inadequate emptying of the breasts and stasis of the milk (Janke, 2014). ● Symptoms: palpation of tender breast lumps the size of peas (Janke, 2014) ● Treatments: ● Frequent feedings ● Changing infant feeding positions (Janke, 2014) ● Application of warm compresses to breast or taking a warm shower prior to feeding session ● Massaging the breasts prior to feeding session ● Continued milk stasis or unresolved plugged milk ducts can lead to mastitis and potential breast abscess (Janke, 2014). ● Patient education ● Encourage the woman to wear a supportive but nonconstrictive bra. ● Instruct the woman to examine her nipples before feedings for signs of irritation. ● After feeding, the woman should expose her nipples to air. ● Improper latch should be adjusted to decrease nipple tissue breakdown (James, 2014). ● Instruct the woman to feed her infant frequently on demand or express milk if she is experiencing breast engorgement. ● Encourage the woman to wash her hands frequently and to keep her breasts clean to prevent infection. ● Provide information on mastitis. ● Mastitis typically occurs at 3 to 4 weeks postbirth. ● The infection may be caused by bacterial entry through cracks in the nipples and is associated with milk stasis, engorgement, long intervals between feedings, stress, and fatigue (Janke, 2014). ● Symptoms include fever, chills, malaise, flulike symptoms, unilateral breast pain, and redness and tenderness in the infected area. ● The woman needs to report symptoms to her health care provider. ● A culture of the breast milk may be ordered prior to starting the woman on antibiotics. ● Treatment: Empty the affected breast, antibiotic therapy, analgesia, rest, adequate nutrition, and hydration. ● The woman should continue to breastfeed or pump her breasts as per the physician's or midwife's recommendation. ● The woman should apply moist heat to the affected breast before breastfeeding. ● Document findings, interventions, and evaluation.

CRITICAL COMPONENT Excessive Bleeding and Early Warning Signs

Each year in the United States, almost 3% of all births result in postpartum hemorrhage, often signified by heavy lochia. Immediate nursing actions include the following: • Assess the position, tone, and location of the fundus. • If the uterus is boggy, massage it. • If the uterus is boggy and displaced to the side, instruct the patient to void and reevaluate. • Ambulate the patient to the bathroom and measure the void. A good void is at least 300 cc. • Quantify blood loss (QBL) by weighing all blood-soaked peripads and materials. • 1 g equals 1 mL of fluid. • QBL provides an accurate estimation of blood loss. • A scale with an attached laminated card with the dry weights of peripads/chux should be available on units providing care to postpartum patients (AWHONN, 2015b) • Notify the midwife or physician of excessive bleeding and QBL. Continued heavy bleeding with firm fundal tone may indicate the presence of a genitourinary tract laceration or hematoma of the vulva or vagina (Hobel & Lamb, 2016). Be alert to early warning signs. It is important to verify isolated abnormal measurements, particularly for blood pressure, heart rate, respiratory rate, and oxygen saturation. Urgent bedside evaluation is usually indicated if any of these values persist for more than one measurement, present with additional abnormal parameters, or recur more than once (Box 12-2). While awaiting the arrival of the evaluating clinician, the bedside nurse should follow basic resuscitation principles: • Achieve free-flowing appropriate venous access • Increase frequency of vital signs • Left uterine displacement if woman is still pregnant • Supplemental oxygen therapy Appropriate standing orders are needed to allow the bedside nurse to administer these resuscitative measures

THE GASTROINTESTINAL SYSTEM from the book

Gastrointestinal muscle tone and motility decrease postbirth with a return to normal bowel function by the end of the second postpartum week. ● Constipation ● Women are at risk for constipation due to decreased GI motility from the effects of progesterone, decreased physical activity, dehydration and fluid loss from labor, fear of having a bowel movement after perineal lacerations or episiotomy, and perineal pain and trauma. ● Hemorrhoids ● Women commonly develop hemorrhoids during pregnancy and/or the birthing process. Hemorrhoids often slowly resolve but can be painful. Sometimes hemorrhoids persist postpartum. ● Appetite ● Women are hungry after the birthing experience and can be given a regular diet, unless they are on a prescribed diet such as for diabetes. Women are exceptionally hungry during the first few postpartum days and may require snacks between meals. ● Weight loss ● Most women will experience significant weight loss during the first 2 to 3 weeks postpartum. Immediately after birth, women lose approximately 11 to 12 pounds as the result of delivery and blood loss. ● Diuresis results in the loss of approximately another 5 to 8 pounds postdelivery (Cunningham et al., 2014). ● The average American woman at the end of 6 months postpartum is approximately 3 pounds above her prepregnancy weight

stage 2 of ob hemorrhage

Hemorrhage: Continued bleeding EBL up to 1,500 mL OR >2 uterotonics with normal vital signs and lab values Initial Steps Mobilize additional help Place second IV (16-18G) Draw STAT labs (CBC, coagulation studies, fibrinogen) Prepare OR Medications Continue Stage 1 medications Blood Bank Obtain 2 units RBCs (DO NOT wait for labs. Transfuse per clinical signs/symptoms). Thaw 2 units fresh frozen plasma ACTION Escalate therapy with goal of hemostasis Huddle and move to Stage 3 if continued blood loss and/or abnormal vital signs

FOLLOW-UP CARE

In the weeks after birth, a woman must adapt to multiple physical, social, and psychological changes. She must recover from childbirth, adjust to changing hormones, and learn to feed and care for her newborn. In addition to being a time of joy and excitement, this "fourth trimester" can present considerable challenges for women, including lack of sleep, fatigue, pain, breastfeeding difficulties, stress, depression, lack of sexual desire, and urinary incontinence. Guidelines recommend that all women attend a postpartum follow-up visit 4 to 6 weeks after birth, or sooner if complications are present. However, as many as 40% of women do not attend a postpartum visit. Attendance rates are lower among populations with limited resources. The comprehensive postpartum visit includes a full assessment of physical, social, and psychological well-being, with screening for postpartum depression using a validated instrument such as the Edinburgh Postnatal Depression Scale. Birth spacing recommendations and reproductive life plans should be reviewed and a commensurate contraceptive method provided. Systems should be in place to ensure that women who desire long-acting reversible contraception or another form of contraception can receive it during the comprehensive postpartum visit if placement wasn't done immediately after birth. Vaccination history should be reviewed and immunizations provided as needed. Women should be asked about common postpartum concerns, including perineal or cesarean wound pain, incontinence, dyspareunia, fatigue, depression, anxiety, and infant feeding problems, and identified concerns addressed. Suggested topics for anticipatory guidance include infant feeding, expressing breast milk if returning to work or school, postpartum weight retention, sexuality, physical activity, and nutrition. Smoking and substance use cessation should be addressed and are discussed in the following section.

Mastitis

Mastitis is an inflammation/infection of the breast tissue that is common among lactating women. It usually occurs in just one breast, most often in the upper outer breast quadrant. Although it usually occurs in the first 3 to 6 months of breastfeeding, it can happen at any time. The most common organism reported in mastitis is Staphylococcus aureus. The organism usually comes from the breastfeeding infant's mouth or throat. Patients with mastitis have very tender, engorged, erythematous breasts, and infection is frequently unilateral. Mastitis is generally self-limiting, and continued breastfeeding can help clear up the infection and condition. It does not harm the baby. If antibiotic therapy is indicated, the infection generally resolves within 24 to 48 hours of antibiotic therapy. Abscess formation can occur in 10% of women who develop mastitis.

Maternal Safety Bundle: Obstetric Hemorrhage

Maternal Safety Bundle Obstetric Hemorrhage A leading cause of maternal morbidity and mortality is failure to recognize excessive blood loss during childbirth (Joint Commission, 2010). Women die from obstetric hemorrhage because effective interventions are not initiated early enough. Hemorrhage is the most frequent cause of severe maternal morbidity and preventable maternal mortality and therefore is an ideal topic for the initial national maternity patient safety bundle. These safety bundles outline critical clinical practices that should be implemented in every maternity unit (ACOG, 2015a; Main et al., 2015). Obstetric Hemorrhage: Key Elements 4 Rs Obstetric Hemorrhage Safety Bundle From the National Partnership for Maternal Safety, Council on Patient Safety in Women's Health Care Readiness (Every Unit) ● Hemorrhage cart with supplies, checklist, and instruction cards for intrauterine balloons and compressions stitches ● Immediate access to hemorrhage medications (kit or equivalent) ● Establish a response team—who to call when help is needed (blood bank, advanced gynecologic surgery, other support and tertiary services) ● Establish massive and emergency release transfusion protocols (type-O negative/uncross-matched) ● Unit education on protocols, unit-based drills (with post-drill debriefs) Recognition and Prevention (Every Patient) ● Assessment of hemorrhage risk (prenatal, on admission, and at other appropriate times) ● Measurement of cumulative blood loss (formal, as quantitative as possible) ● Active management of the third stage of labor (department-wide protocol) Response (Every Hemorrhage) ● Unit-standard, stage-based, obstetric hemorrhage emergency management plan with checklists ● Support program for patients, families, and staff for all significant hemorrhages Reporting and Systems Learning (Every Unit) ● Establish a culture of huddles for high-risk patients and post-event debriefs to identify successes and opportunities ● Multidisciplinary review of serious hemorrhages for systems issues ● Monitor outcomes and process metrics in perinatal quality improvement (QI) committee

maternal mortality from the book

Maternal mortality is the death of a woman from complications of pregnancy and childbirth occurring up to 1 year postpartum. In a report using data from 2010, the United States ranked 49th out of 184 countries for maternal mortality (Central Intelligence Agency, 2016) and is one of eight countries in which maternal mortality rates have been on the rise in recent years. Although the most current U.S. pregnancy-related mortality rate shows a slight decrease in maternal deaths, from 17.8 deaths per 100,000 live births in 2011 to 15.9 deaths per 100,000 live births in 2012 (Centers for Disease Control and Prevention [CDC], 2016b), this rate is more than double the 1987 rate of 7.2 deaths per 100,000 births. Increased rates may be related to improvements in reporting, but the number is still high for a country with readily available medical care. The CDC and the Department of Health and Human Services Office of Disease Prevention and Health Promotion have set national health goals published in Healthy People 2020, several of which relate to the postpartum period

PPD management and nursing actions

Medical/Psychiatric Management ● Mild PPD ● Interpersonal psychotherapy (Yonkers, Vigod, & Ross, 2011) ● Moderate PPD ● Interpersonal psychotherapy ● Antidepressants (Yonkers, Vigod, & Ross, 2011). ● Severe PPD or suicidal ideation ● Intense psychiatric care ● Crisis interventions ● Interpersonal psychotherapy ● Antidepressants ● Electroconvulsive therapy (Yonkers, Vigod, & Ross, 2011) Nursing Actions ● Review prenatal record for risk factors. ● Monitor mother-infant interactions more closely for women at risk for PPD. ● Anticipatory guidance: Teach the woman and her partner signs of PPD that should be reported to her health care provider. ● Be supportive and encouraging in interactions. ● Provide the woman with information regarding postpartum support groups and other community resources to assist her with parenting issues and to provide support. ● Postpartum support by health care professionals can mitigate the onset of postpartum mood disorders

more notes on the postpartum period

Moms like to talk about their delivery a lot: this is how they process what happened Pg. 368 know the pictue Uterus is about 2lbs at delivery and has to get back to its normal size of a few ounces after delivery (during the postpartum period) If you don't see it you don't need to chart it; don't just ask the patient Anytime you have a wound you need to do a REEDA assessment -redness -edema -ecchymosis -Discharge -approximation To examine get patient on the left side and lift the buttock to get a good look

Gestational Diabetes

Most women with gestational diabetes return to normal glucose tolerance postpartum (Daley, 2014). Although the carbohydrate intolerance of GDM frequently resolves after delivery, up to one-third of affected women will have diabetes or impaired glucose metabolism at postpartum screening, and it has been estimated that 15% to 50% will develop type 2 diabetes later in life (ACOG, 2013). Postpartum screening at 6 to 12 weeks is recommended for all women who had GDM to identify women with diabetes mellitus (DM), impaired fasting glucose levels, or impaired glucose tolerance. Follow-up is essential to ensure normal fasting glucose values. Nursing Actions The nurse must counsel women with a history of GDM that they have a sevenfold increased risk of developing type 2 diabetes compared with women with no GDM history (ACOG, 2013a). Counseling can be provided to women with a history of GDM to modify risk factors such as obesity with weight reduction and exercise. Women should also be informed they are at high risk for developing GDM with subsequent pregnancies. For women who may have subsequent pregnancies, more frequent screening can detect abnormal glucose metabolism before pregnancy and provides an opportunity to ensure preconception glucose control (ACOG, 2013a). Women should be encouraged to discuss their GDM history and need for screening with their health care providers. Exercise or increased activity is recommended for women with a high risk of diabetes, such as those with a history of GDM. Exercise independent of weight loss has a role in preventing or delaying the development of overt diabetes, due to the resulting decrease in insulin resistance. Additionally, inactivity is a risk factor for the development of T2DM (AWHONN, 2016). Explore challenges related to the prevention of overt diabetes. Strategies include: ● Assessing knowledge, risk perception, self-efficacy, current prevention behaviors, and intention to change behavior. ● Identifying barriers to health promoting behaviors and solutions to promote behavior change. ● Identifying social support (including family/support system) in education, counseling, and problem solving. ● Designing interventions that are individualized and easily accessible, such as phone counseling and computer-based education. ● Providing information about resources such as exercise classes and diet advice. ● Providing links as needed to dietitians, primary care providers, and mental health professionals to ensure ongoing support. ● Breastfeeding, which is strongly recommended after delivery for all women with pregestational diabetes mellitus or gestational diabetes mellitus. ● Schedule a follow-up appointment 2 to 6 weeks postdischarge with the provider who managed diabetes during pregnancy.

CRITICAL COMPONENT Quantification of Blood Loss After Birth

Normal blood loss for a vaginal birth is approximately 500 mL within 24 hours. Visual estimation of blood loss (EBL) is common practice in obstetrics; however, the inaccuracy of EBL has been well established and blood loss can be underestimated by up to 50% (AWHONN, 2014b). AWHONN recommends that cumulative blood loss be formally measured or quantified after every birth. Inaccurate measurement of postpartum blood loss has the following implications: Underestimation can lead to delay in delivering lifesaving hemorrhage interventions. Overestimation can lead to costly, invasive, and unnecessary treatments such as blood transfusions that expose women to unnecessary risks. Direct measurement of blood loss can be accomplished by two complementary approaches. The easiest is to collect blood in calibrated, under-buttocks drapes for vaginal birth. The second approach is to weigh blood-soaked items and clots. These items can be collected in a single bag and weighed using a gravimetric method. By using this method, the weight of dry pads is subtracted from the total weight to obtain an estimate of blood loss. Weigh all blood-soaked materials and clots to determine cumulative volume

SAFE AND EFFECTIVE NURSING CARE: Understanding Medication Oxytocin (Pitocin)

Oxytocin stimulates the upper segment of the myometrium to contract rhythmically, which constricts spiral arteries and decreases blood flow through the uterus. Oxytocin is an effective first-line treatment for postpartum hemorrhage. As a high-alert medication, IV oxytocin premixed bags should be prominently and clearly labeled and stored separately to prevent a 1,000 mL bag of oxytocin being mistaken for a plain 1,000 mL bag of resuscitation bolus (Association of Women's Health, Obstetric and Neonatal Nurses [AWHONN], 2015a). Universal Active Management of Third Stage of Labor ● Increase IV oxytocin rate, 500 mL/hour of 10 to 40 units/500-1,000 mL solution. ● Titrate infusion rate to uterine tone, up to 500 mL as needed. ● Indication: Postpartum control of bleeding. ● Action: Stimulates uterine smooth muscle to produce uterine contraction. ● Adverse reactions with IV use: coma, seizures, hypertension, hypotension, water intoxication. ● Administer via IV infusion using an IV infusion pump, or via the intramuscular (IM) route if the patient does not have IV access. ● Premixed bags of IV fluid containing oxytocin should be clearly marked with bright labels and stored in a different area than plain IV fluid bags. ● Suggested administration: 20 units of oxytocin in 1 L of normal saline or lactated Ringer's. ● Bolus at a rate of 1,000 mL/hr for 30 minutes (10 units of oxytocin), immediately after birth followed by a maintenance dose of 125 mL/hr for 3.5 hours. ● Women who delivered by cesarean section or who are at high risk for postpartum hemorrhage may require continuation of oxytocin administration for greater than 4 hours. Duration and dosage is based on assessment of fundal tone and amount of vaginal bleeding (AWHONN, 2015a). ● For postpartum bleeding, a total of 10 to 40 units may be infused intravenously at a rate of 20 to 40 mU/min, depending on the patient's condition (Wilson et al., 2014). ● For patients without IV access, administer 10 units of oxytocin IM. ● Nursing actions/implications: Monitor vital signs frequently; assess fundal position, tone, and location; assess lochia color amount and odor; assess for signs of water intoxication (drowsiness, headache, anuria); and teach patient that oxytocin will cause uterine cramping. ● Have other uterotonics on hand such as methylergonovine (Methergine), misoprostol (Cytotec), and carboprost (Hemabate).

Postpartum Depression

PPD is classified as a major depressive disorder when the woman has a depressed mood or a loss of interest or pleasure in daily activities for at least 2 weeks in addition to four of the following symptoms: ● Significant weight loss or gain: a change of more than 5% of body weight in a month ● Insomnia or hypersomnia ● Changes in psychomotor activity: agitation or retardation ● Decreased energy or fatigue ● Feelings of worthlessness or guilt ● Decreased ability to concentrate; inability to make decisions Risk Factors ● History of depression before pregnancy ● Depression or anxiety during pregnancy ● Inadequate social support ● Poor quality relationship with partner ● Life and child care stresses ● Complications of pregnancy and/or childbirth ● Single ● Low socioeconomic status Assessment Findings ● Sleep and appetite disturbance ● Fatigue greater than expected when caring for a newborn ● Despondency ● Uncontrolled crying ● Anxiety, fear, and/or panic ● Inability to concentrate ● Feelings of guilt, inadequacy, and/or worthlessness ● Inability to care for self and/or baby ● Decreased affectionate contact with the infant

Activity and Exercise

Physical activity is good for the overall health of postpartum women with no other medical problems. For example, moderate-intensity physical activity, such as brisk walking, keeps their heart and lungs healthy after pregnancy. Physical activity also helps improve mood throughout the postpartum period. Exercise helps maintain a healthy weight, and when combined with eating fewer calories helps with weight loss (CDC, 2015). Healthy women should get at least 150 minutes (2.5 hours) per week of moderate-intensity aerobic activity such as brisk walking. While 150 minutes each week sounds like a lot of time, women can break it into smaller chunks throughout the week. In fact, it is best to spread activity out during the week, as long as you exercise with moderate or vigorous effort for at least 10 minutes at a time. ● Explain the importance of activity to decrease risk of constipation and to promote circulation and a sense of well-being. ● Instruct the woman about appropriate exercises in the post-partum period, such as walking. ● Encourage the woman to do Kegel exercises to strengthen the pelvic floor.

Urinary Tract Infection

Risk Factors ● Epidural anesthesia, which decreases the woman's ability to feel the urge to void, leading to an increased risk for an over-distended bladder ● Overdistended bladder or incomplete emptying of the bladder, which can cause an increase of bacterial growth in the bladder ● Urinary catheter inserted during the labor process ● Neonatal macrosomia, which can cause edema around the urethra ● Operative vaginal deliveries, forceps, or vacuum extractor, which can cause edema around the urethra ● Intrapartal vaginal exams and the birth process, which can contaminate the urethra with bacteria Assessment Findings ● Low-grade fever (101.3°F [38.5°C]) ● Burning on urination ● Suprapubic pain ● Urgency to void ● Small, frequent voidings—less than 150 mL per voiding Medical Management ● Urinalysis, CBC, and urine culture and sensitivity ● Antibiotics (usually PO) started before culture results Nursing Actions ● Risk reduction for UTI ● Assist the woman to the bathroom to void within a few hours after birth. This will flush bacteria out of the urethra. ● Catheterize the woman if she is unable to void within 2 to 3 hours postbirth. ● Remind the woman to void every 3 to 4 hours; she may not feel the urge to void during the first 24 to 48 hours following birth. ● Measure voidings for the first 24 hours, assessing for complete emptying of the bladder. Each voiding should be equal to or greater than 150 mL. ● Change peripads at least every 3 to 4 hours. Soiled peripads can encourage growth of bacteria that can enter the urethra. ● Remind postpartum women to drink a minimum of 3,000 mL/day (AWHONN, 2006). ● Encourage foods that increase acidity in urine, such as cranberry juice, apricots, and plums. ● Monitor for signs and symptoms of UTI. ● Report findings of possible UTI to the physician or CNM for further evaluation. ● Obtain laboratory specimens as ordered. ● Administer antibiotics as ordered. ● Push oral hydration. ● Discharge teaching ● Provide information on proper use of discharge medications. ● Provide information on signs and symptoms of cystitis and report these changes to the health care provider.

mastitis x2

Risk Factors ● History of mastitis with a previous infant ● Cracked and/or sore nipples ● Using only one position for breastfeeding, which may reduce emptying of the breast ● Wearing a tight-fitting bra ● Poor nutrition ● Ample milk supply and reduction in the number of feedings Assessment Findings ● Breast tenderness or warmth to the touch ● Generally feeling ill (malaise) ● Breast swelling and hardness ● Pain or a burning sensation continuously or while breastfeeding ● Skin redness, often in a wedge-shaped pattern ● Fever of 101°F (38.3°C) or greater Medical Management ● Oral antibiotics therapy for 10 to 14 days ● Culture of expressed milk from affected breast if infection does not resolve Nursing Actions ● Risk reduction: ● Mastitis is less likely to occur with complete emptying of the breasts and good breastfeeding technique. Thus, post-partum nurses must teach breastfeeding patients proper latch-on technique and stress regular breastfeeding and allowing complete emptying of both breasts. Breastfeeding patients are also encouraged to avoid missing feedings and allowing the breasts to become engorged. ● Treatment for mastitis typically involves antibiotic therapy and regular breastfeeding or pumping the breast. Nurses can encourage these patients to apply cold or warm compresses to ease discomfort and to take analgesics as needed. Mastitis usually resolves quickly if patients continue to breastfeed or pump regularly. ● Explain to the woman the importance of washing her hands before feeding to decrease spread of bacteria. ● Proper hand-washing technique by hospital personnel ● Teach the woman methods to decrease nipple irritation and tissue breakdown, such as correct infant latch-on and removal from the breast, more than one breastfeeding position, and air-drying nipples after feedings (refer to Chapter 16 for additional information). ● Teach the woman the importance of a healthy diet and adequate fluids to decrease risk for any infection. ● Recommend that the patient consider a larger bra size as breast size changes. ● Recommend massaging the breast during breastfeeding, especially over tender areas and under the armpit, a common location of engorgement. ● Empty both breasts fully during breastfeeding. ● Palpate and inspect the breasts for signs of mastitis. ● Report assessment data of possible mastitis to physician or CNM. ● Administer antibiotics as ordered. ● Administer analgesia as ordered. ● Apply warm compresses to the affected area for comfort and promotion of circulation. ● Instruct the woman to continue to breastfeed or to massage and express milk from the affected breast to promote continuation of milk flow. ● Explain to the woman that it is very common for lactating women to experience mastitis and that it is easily treated when identified early.

wound infections x2

Risk Factors ● Obesity ● Diabetes ● Malnutrition ● Long labor ● Prolonged operative time during cesarean section ● Premature rupture of membranes ● Preexisting infection, including chorioamnionitis ● Immunodeficiency disorders ● Corticosteroid therapy ● Poor suturing technique Assessment Findings ● Erythema ● Heat ● Swelling ● Tenderness ● Purulent drainage ● Low-grade fever ● Increased pain at incision or laceration site Medical Management ● Obtain a culture specimen from the wound or laceration if indicated. ● For mild to moderate wound infections that do not have purulent drainage: ● Administer oral antibiotic therapy. ● Apply warm compresses to area. ● Wound infections with purulent drainage: ● Open and drain the wound. ● IV antibiotic therapy. Nursing Actions ● Assess perineum or surgical incision for REEDA (redness, edema, ecchymosis, discharge, approximation of edges of episiotomy or laceration). Inform physician or midwife of abnormal assessment data. ● Assess vital signs. ● Obtain laboratory specimens such as cultures as ordered. ● Review laboratory reports and notify the physician or midwife of abnormal results. ● Administer antibiotics as ordered. ● Pain management ● Administer analgesia for fever and discomfort as ordered. ● Apply hot packs for abdominal wounds or sitz bath for perineal wounds to promote comfort and circulation. ● Use proper hand-washing technique before and after contact with the wound. ● Provide education on proper diet, fluids, and rest that can decrease the risk for infection and assist in the healing process. ● Provide information on proper use of discharge medications.

The Maternal Early Warning Criteria

Systolic blood pressure (mm Hg)<90 or >160 Diastolic blood pressure (mm Hg)>100 Heart rate (bpm)<50 or >120 Respiratory rate (breaths per min)<10 or >30 Oxygen saturation on room air, at sea level %<95 Oliguria, mL/hr for ≥2 hrs<35 Maternal agitation, confusion, or unresponsiveness Women with preeclampsia reporting a unremitting headache or

THE IMMUNE SYSTEM

The immune system, which is suppressed during pregnancy, returns to normal in the postpartum period (Isley & Katz, 2016). It is common for the postpartum woman to experience mild temperature elevations during the first 24 hours postbirth related to muscular exertion, exhaustion, dehydration, or hormonal changes. A temperature greater than 100.4°F (38°C) after the first 24 hours on two occasions may be indicative of postpartum infection and requires further evaluation. Women who are rubella nonimmune should be immunized for rubella before discharge (Cunningham et al., 2014). Women may be required to sign a consent form prior to administration of the vaccine. Women may also receive vaccinations such as Tdap (tetanus, diphtheria, and pertussis), hepatitis B, varicella, and influenza if needed in the postpartum period (American College of Obstetricians and Gynecologists [ACOG], 2013, 2018; CDC, 2016a). Rh isoimmunization occurs when an Rh-negative woman develops antibodies to Rh-positive blood related to exposure to Rh-positive blood either by blood transfusion or during pregnancy with a Rh-positive fetus. Women who are sensitized produce IgG anti-D (antibody), which crosses the placenta and attacks the fetal red blood cells, causing hemolysis. Rh isoimmunization is preventable.

Nutrition and Fluids

The nurse must provide instruction about nutritional needs for lactating and nonlactating women. ● Lactating women should increase their caloric intake by 500 to 1,000 calories per day and have a fluid intake of approximately 2 to 3 liters per day. ● Teach lactating women that there is no evidence that an occasional alcoholic drink is harmful (Niebyl, Weber, & Briggs, 2016); however, the long-term effects of daily alcohol use on breastfeeding infants is unknown, so alcoholic beverages should be kept to a minimum. If a woman does drink, she should wait for 2 to 2.5 hours per drink before nursing (TOXNET, 2017). ● Teach the woman how to use MyPlate (www.ChooseMyPlate.gov) and how this can assist in meeting her nutritional needs (Fig. 12-5). Women who are anemic should increase consumption of leafy green vegetables, beans, red meat, poultry, iron-fortified cereal, breads, pasta, and dried fruits such as raisins. To prevent constipation, women who have hemorrhoids, perineal lacerations, or episiotomy should consume foods that add roughage to their diets such as fruits, vegetables, beans, and whole grains. Woman should drink a minimum of 10 glasses of fluids per day, or 80 ounces.

hemorrhage x2

The primary source of blood loss is from the placental site. The increase of blood volume and red blood cells (RBC) during pregnancy normally compensates for the blood loss that occurs following the detachment of the placenta. Additionally, physiological changes during pregnancy and immediately after the expulsion of the placenta decrease the amount of blood loss from the placental site. These physiological changes include the following: ● Hypercoagulability ● Factor VIII complex increases during pregnancy. ● Factor V increases following placental separation. ● Platelet activity increases during pregnancy. ● Fibrin formation increases during pregnancy. ● Contractions of the uterine myometrium ● Blood vessels that supply the placental site pass through the myometrium, an interlacing network of smooth muscle fibers. ● Contractions of the myometrium compress the blood vessels at the placental site, thus decreasing the amount of blood loss. An estimated 5% of postpartum women will experience a PPH (Harvey & Dildy, 2012). Major complications of PPH include hemorrhagic shock related to hypovolemia, disseminated intravascular coagulation (DIC), organ failure, and death. The primary causes of PPH in descending order of frequency are the "4 Ts": ● Tone: uterine atony ● Tissue: retained placental fragments ● Trauma: lower genital track lacerations ● Thrombin disorders: disseminated intravascular coagulation (Table 14-1). PPH is classified as primary (early) and secondary (late) hemorrhage. Primary PPH occurs within the first 24 hours after childbirth and is caused by uterine atony, lacerations, or hematomas. Secondary PPH occurs 24 hours to 6 weeks postdelivery and is caused by hematomas, subinvolution, or retained placental tissue.

more notes on the reproductive system

Uterine involution is faster in breastfeeding moms Tone: boggy is bad and firm is good Location: full bladder can offset the uterus and that leads to a soft fundus REEDA: redness, edema, ecchymosis, discharge, approximation When we are assessing these things (reproductive system): we want to give the mothers the best opportunity for privacy -close door, pull curtain, only expose necessary area Uterine atony is a big thing we are looking for -if the uterus is not firm then we are looking at the potential for PPH. Greatest risk during first hour of delivery but can occur in the first 24 hours, This is primary or early .but can can happen anywhere from 24 hrs to 12 weeks Before you assess her uterus: Introduce yourself, wash hands, tell her what to expect, empty bladder due to a full bladder to displace the uterus and increases the risk for pph, lower head and foot so she's flat, look at pads and assess lochia, put one hand above symphysis pubis to stabilize and the other hand at the fundus of the uterus and feel for that grapefruit feeling if its nice and firm If we have a boggy uterus -massage massage massage, get that thing contracting, if blood loss then you start oxytocin back to stimulate contractions -If we are massaging and have Pitocin going and the bleeding Is still not stopping, we need to notify the provider because we may need to go to a next level drug and the HCP may have to come and examine for things like a cut cervix or some other birth trauma - -Clots don't always mean something bad, it could come from blood sitting in the vaginal vault and when they stand up they could just come out at that point

Acute Onset of Severe Hypertension Postpartum

Women in the postpartum period with acute-onset, severe systolic (greater than or equal to 160 mm Hg) hypertension, severe diastolic (greater than or equal to 110 mm Hg) hypertension, or both require urgent antihypertensive therapy. The goal is not to normalize BP but to achieve a range of 140-150/90-100 mm Hg to prevent repeated, prolonged exposure to severe systolic hypertension. In the event of a hypertensive crisis with prolonged uncontrolled hypertension, maternal stabilization should occur before delivery even in urgent circumstances. Treatment with first-line agents should be expeditious and occur as soon as possible within 30 to 60 minutes of confirmed severe hypertension to reduce the risk of maternal stroke. IV labetalol and hydralazine have long been considered first-line medications for the management of acute-onset, severe hypertension in pregnant women and women in the postpartum period. Immediate-release oral nifedipine also may be considered as a first-line therapy, particularly when IV access is not available. It is important to note differences in recommended dosage intervals between these options, which reflect differences in their pharmacokinetics. Protocols should be followed for maternal monitoring of blood pressure every 5 to 15 minutes. None of the recommended drugs require cardiac monitoring. Although all three medications are appropriately used for the treatment of hypertensive emergencies in pregnancy, each agent can be associated with adverse effects. Parenteral hydralazine may increase the risk of maternal hypotension (systolic BP 90 mm Hg or less). Parenteral labetalol may cause neonatal bradycardia and should be avoided in women with asthma, heart disease, or congestive heart failure. Nifedipine has been associated with an increase in maternal heart rate, and with overshoot hypotension (ACOG, 2017a). Extensive discussion of preeclampsia is in Chapter 7 -Requires urgent treatment Notify physician for headaches or vision problems They may send her home on PO bp meds

Disseminated Intravascular Coagulation

a syndrome in which the coagulation pathways are hyperstimulated. When this occurs, the woman's body breaks down blood clots faster than it can form them, quickly depleting the body of clotting factors and leading to hemorrhage and death. ● DIC is a complication of an underlying pathological process called anaphylactoid syndrome of pregnancy. ● Women who experience DIC are transferred to critical care units, and a perinatologist, when available, manages their care. Risk Factors ● Abruptio placenta, the primary cause of DIC ● HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome ● Anaphylactoid syndrome of pregnancy ● Hemorrhage Assessment Findings ● Prolonged, uncontrolled uterine bleeding ● Bleeding from the IV site, incision site, gums, and bladder ● Purpuric areas at pressure sites, such as blood pressure cuff site ● Abnormal clotting study results, such as low platelets and activated partial thromboplastin time ● Increased anxiety ● Signs and symptoms of shock related to blood loss: ● Pale and clammy skin ● Tachycardia ● Tachypnea ● Hypotension Medical Management Medical management focuses on optimizing hemodynamic function and improving overall tissue oxygenation while identifying and eliminating the underlying pathology (Sisson & Mann, 2013). ● Laboratory tests (e.g., fibrinogen levels, prothrombin time [PT], partial thromboplastin time [PTT], and platelet count) to assess for abnormal clotting ● Identification of the primary cause of bleeding and intervention based on this knowledge ● IV therapy ● Blood replacement ● Platelet transfusion ● Fresh frozen plasma ● Cryoprecipitate ● Oxygen therapy Nursing Actions ● Reduce risk of DIC. ● Review prenatal and labor records for risk factors. ● Monitor women more frequently who are at risk for DIC. ● Assess for PPH and intervene appropriately. Early intervention can decrease the risk of DIC. ● Monitor vital signs and immediately report to the MD or CNM abnormal findings, such as an increase in heart rate, a decrease in blood pressure, and a change in quality of respirations. ● Obtain IV site with large-bore intracatheter as per orders. ● Administer IV fluids as ordered. ● Administer oxygen as ordered. ● Obtain laboratory specimens as ordered. ● Review laboratory results and notify the physician of results. ● Start blood transfusion as ordered. ● Provide emotional support and information to the woman and her family to decrease level of anxiety. ● Facilitate transfer to ICU.

Anaphylactoid Syndrome of Pregnancy

amniotic fluid embolism Assessment Findings ● Dyspnea ● Seizures ● Hypotension ● Cyanosis ● Cardiopulmonary arrest ● Uterine atony that causes massive hemorrhage and leads to DIC ● Cardiac and respiratory arrest Medical Management ● No scientific data exists to support any intervention that improves maternal prognosis with anaphylactoid syndrome of pregnancy. ● The focus is on maintaining cardiac and respiratory function, stopping the hemorrhage, and correcting blood loss. ● Complete blood count (CBC), platelet count, arterial blood gases, fibrinogen, and prothrombin time are a few of the laboratory tests that might be ordered. ● Blood type and screen for possible transfusion ● Chest x-ray exam ● Blood replacement, packed red blood cells, and platelets ● Transfer to the critical care unit. ● A heart-lung bypass machine, when available, may be used to help stabilize the woman. Nursing Actions ● Monitor for signs of anaphylactoid syndrome of pregnancy. ● Notify the physician immediately of assessment data so that early interventions can be initiated. ● Administer oxygen. ● Establish two IV sites with large-bore intracatheters: one for IV fluid replacement and one for blood replacement. ● Obtain laboratory specimens as ordered. ● Administer blood replacement as ordered. ● Provide emotional support to the woman and her support system. ● Call code and initiate CPR when indicated. ● Facilitate transfer to ICU.

Endometrium

the mucous membrane that lines the uterus, undergoes exfoliation and regeneration after the birth of the placenta through necrosis of the superficial layer of the decidua and regeneration of the decidua basalis into endometrial tissue. Lochia is a bloody discharge from the uterus that contains red blood cells, sloughed off decidual tissue, epithelial cells, and bacteria (Cunningham et al., 2014). The placental site heals by exfoliation, which involves the sloughing of necrotic endometrial tissue and the regeneration of the endometrium at the placental site (Cunningham et al., 2014; Smith, 2018). This process prevents scarring of the endometrial tissue (James, 2014). Lochia undergoes changes that reflect the healing stages of the uterine placental site (Table 12-2). Uterine contractions constrict the vessels around the placental site and help decrease blood loss.

trauma: hematoma (may be vulvar, vaginal, cervical, or retroparitoneal)

• Firm uterus • Sudden onset of painful perineal pressure • Bulging area just under the skin • Difficulty voiding or sitting • Assess for visible hematoma • Call provider to assess • Anticipate possible excision and ligation if >3 cm • Consider indwelling catheter • Continue to assess vital signs, blood loss, and fluid maintenance • Pain management, including ice to the area

Thrombin disorders

• Preeclampsia • Stillbirth • Disseminated (systemic) intravascular coagulopathy (DIC) • Oozing from IV sites • Nosebleeds • Petechiae • Bleeding gums • Hypotension and other signs of shock • Abnormal clotting lab values • Early recognition is key factor in survival • Confirm accurate blood loss estimates • Monitor lab values, vital signs, intake and output • Manage systemic manifestations such as volume replacement, platelets IV, oxygen by mask at 10 L/min

The Endocrine System

•Abrupt changes in hormones •Nursing actions Cut off estrogen after delivery -Abrupt changes -diaphoresis -night sweats -expected -hair loss

The Muscular and Nervous Systems

•Assess for diastasis recti abdominis •Relieve muscle soreness after delivery •Assess for return of sensation, headache, fatigue •Promote rest and sleep •Nursing actions Mom is going to be tired Promotes naps

Discharge Teaching and Follow-up

•Comprehensive assessment and depression screening within 4 to 6 weeks •Many women do not have postpartum follow-up •Discharge teaching topics •Warning signs: bleeding (a saturated pad within an hour is to much and could indicate a secondary hemorrhage), fever , foul smelling lochia, wound looks infectious, UTI signs, leg pain, redness of DVT, depression, clogged milk duct(red, sore, hard spot) If your not going to wait need to asses birth control She should change her pad every time you go to the bathroom or every 3-4 hours

Coagulation Disorders

•D I C: everything shutting down and finna start bleeding from everywhere. We want to do whatever we can to prevent this •Anaphylactoid syndrome: amniotic fluid embolism: a little of mixing of fetal circulation and maternal circulation happens and can cause an emergent situation •V T E: dyspnea and chest pain. Know signs of an imprending PE

Postpartum Period

•First 6 weeks after delivery •Rapid physical, social, and emotional adaptation •Assessment: bubble he •Breast: pain tenderness lumps ect.. •Uterus •Bladder •Bowel •Lochia •Emotion/episiotomy •Homans sign: don't do it anymore (dorsiflex the foot and look for pain)

The Cardiovascular System

•Immediate postpartum changes: •Average E B L 200-500 milliliters •Assessment of postpartum vital signs •Lung sounds and heart sounds, vital signs every 15 minutes (same protocol for tone assessment) •Nursing actions 1000ml for c-section is to much 500 ml for vaginal is to much

summary of ch12

•Physical/hormonal changes during postpartum period •Postpartum assessment •Follow-up visits •Patient teaching •Discharge teaching When we lie flat the blood can pool so when you stand up a gush of blood could come out Pg. 370 know different lochia's, what day they occur on Know amounts on 370 as well Ice is effective for only the first 24 hours May give a topical ointment or spray for the stitches: about 3 times a day

Infections: Endometritis

•Risk factors: anything that can introduce bacteria to the uterus •Assessment •Management: 3000 ml/day to flush out , hand wash before and after anything •Nursing actions Infection of the uterus like the endometrium Can be infecte by anerobic or aerobic bacteria The lochia heavy and foul smelling: endometrium is involved If lochia is scant and odorless is GBS Post partum depression could be faked in the first, post partum depression is the #1 cause of mortality in post partum - Can be treated with antidepressants, but they take 3 weeks to kick in so if its that bad you may need immediate intervention form inpatient help

Reproductive System

•Uterine involution: the process from a 2lb uterus at delivery to like 2 ounces at normal size •How do we assess where she is in this process? fundal position, tone is it firm or boggy, and location related to her umbilicus •Endometrial healing: lochia look at , color, amount, and odor) •Vagina and perineum (R E E D A: if there was a cut and, also if there is an c-section incision) •Breast, breastfeeding: palpate breast and make sure there is no abnormalities, feeling for fullness to see milk volume, colostrum, •Nursing assessment and actions: look at uterus every 15 minutes for the first hour, every 30 minutes for the second hour, every 4 hours for the next 22 hours, and every shift after the first 24 hours or as stated in the unit protocols. More frequently if the findings are not WNL

nursing actions for the GI system

● Assess bowel sounds at each shift. ● Notify the physician or midwife if bowel sounds are faint or absent. ● Rationale: Decreased motility can lead to diminished peristalsis and intestinal obstruction. ● Assess for constipation. ● Ask the woman if and when she had a bowel movement. ● Rationale: Constipation is common in the postpartum period. Bowel function usually returns in 2 to 3 days after delivery (James, 2014). Decreased frequency of bowel movements and the passage of hard, dry stools indicate constipation (Turawa, Musekiwa, & Rohwer, 2015). ● Instruct the woman to increase fluid intake and increase fiber and roughage in diet to decrease risk of constipation. Bring her water and prune juice. Remind her to drink often. ● Rationale: A diet that includes fiber-rich foods (i.e., fruits, vegetables, whole grains, and legumes) promotes intestinal peristalsis. Adequate fluid intake is necessary when women are encouraged to increase dietary fiber to prevent constipation. Intake of 3,000 mL of fluids a day will soften bowel movements and provide adequate mucus to lubricate the colon (James, 2014). ● Ask the woman what she did for constipation during pregnancy or in the past and implement these strategies. ● Encourage ambulation. ● Rationale: Ambulation promotes intestinal peristalsis and reduces the risk for constipation (Turawa et al., 2015). ● Administer a stool softener or laxative as per health care provider's orders. ● Rationale: Stool softeners prevent constipation by increasing water in the stool, promoting stool softening and elimination (Vallerand & Sanoski, 2013). Laxatives are effective in relieving constipation and work by adding bulk to the stools or stimulating the nerves that irritate the intestinal wall (Turawa et al., 2015). ● Docusate sodium (Colace) is a stool softener that helps incorporate water into the stool and can be administered to prevent constipation. ● Route and dose: PO; 100 mg twice a day ● Nursing actions/implications: Administer with a full glass of water or juice; do not administer within 2 hours of other laxatives, such as mineral oil. Effectiveness may take 1 to 3 days after administration. ● Assess for hemorrhoids. ● Rationale: Hemorrhoids may increase in size during labor and cause discomfort in the postpartum period (James, 2014). ● Instruct the woman to lie on her side, then separate the buttocks to expose the anus. ● If hemorrhoids are present: ● Encourage the woman to avoid sitting for long periods of time by lying on her side. ● Witch hazel pads or topical anesthetics can be used to reduce discomfort from hemorrhoids (Isley & Katz, 2016; James 2014). ● Sitz baths are helpful in promoting circulation and reducing pain. ● Assess appetite. ● Assess the amount of food eaten during meals. ● Ask the woman if she is hungry. ● Rationale: In most cases, after a vaginal delivery women can resume eating a regular diet (James, 2014). ● Ask the woman if she is nauseous or has vomited. ● Rationale: Nausea and vomiting may occur during labor. Additionally, nausea is a common side effect of opioid analgesics commonly used for pain management during labor and delivery (Wilkinson & Treas, 2011).

nursing actions for the muscular and nervous systems

● Assess for diastasis recti abdominis. ● The nurse can feel the separation of the rectus muscle when assessing the fundus. ● Reassure the woman that this is normal and will diminish over time. ● Assess for muscle tenderness. ● Rationale: Muscle soreness may result from positioning during labor and delivery, and generalized muscle use during second stage labor/pushing. ● Expected assessment findings: ● Mild to no muscle soreness ● Comfort measures for muscle soreness: ● Ice pack to area for 15 minutes ● Heat to area: Applying heat increases circulation, which facilitates healing. Cold packs result in vasoconstriction and decreased swelling. These interventions may alter the woman's perception of pain according to the gate control theory of pain modulation (Wilkinson & Treas, 2011). Analgesics alter a patient's perception of pain. ● Warm shower ● Analgesia ● Assess for decreased nerve sensation. ● Rationale: Epidural or spinal anesthesia causes lack of sensation that may last several hours into the early postpartum period. Regional anesthesia may interfere with urinary elimination and mobility until the effects wear off. ● Expected assessment findings: ● Full sensation of lower extremities for women who did not receive an epidural during labor. ● Diminished lower body sensation for women who received an epidural during labor with full sensation returning within a few hours postbirth. ● Delay ambulation or assist the woman when ambulating until full sensation has returned. ● Rationale: Women who have received spinal or epidural anesthesia are at risk for falls until full sensation has returned. ● Assess for headache. ● If the woman complains of headache, assess the location and quality of the headache (James, 2014). ● Notify the woman's health care provider if the headache is associated with signs and symptoms of preeclampsia, or if a postepidural/spinal headache is suspected. ● Rationale: Women who have had spinal or epidural anesthesia may develop headaches related to dural puncture and subsequent leakage of cerebrospinal fluid (CSF) leading to decreased levels of CSF. Headaches related to epidural or spinal anesthesia tend to be worse when the patient is in an upright position and improved when the patient is lying down (Sacks & Smiley, 2014). Headache may also be associated with preeclampsia (James, 2014). ● Assess for fatigue ● Rationale: Fatigue is a common complaint among women during the postpartum period. Discomfort and lack of sleep related to infant care activities contribute to feelings of fatigue (James, 2014). ● Promote rest and sleep. ● Provide teaching about the importance of sleep and rest. ● Encourage the woman to sleep/nap while the baby is sleeping and to prioritize activities with a focus on self- and infant care. ● Cluster nursing care such as assessments, interventions, and medication administration. ● Rationale: This minimizes disruptions to the woman's sleep/naps. ● Medicate the woman for pain as per orders and/or offer nonpharmacological interventions if appropriate. ● Rationale: Pain interferes with sleep (Wilkinson & Treas, 2011). ● Document findings and interventions.

nursing actions of the endometrium

● Assess lochia for color, amount, and odor at the same time the uterus is assessed. ● Rationale: Frequent assessment of lochia in the early post-partum period allows the nurse to monitor blood loss and identify if bleeding is excessive, determine if clots are present, and assess for signs of infection. ● Lochia is described as scant, light, moderate, or heavy (Fig. 12-3). ● Scant is less than 1 inch on the pad. ● Light is less than 4 inches on the pad. ● Moderate is less than 6 inches on the pad. ● Heavy is when the pad is saturated within 1 hour; excessively heavy is when a pad is soaked within 15 minutes. ● Assess for clots, which occur when the lochia has been pooling in the lower uterine segment. ● Small clots should be noted in the patient chart. ● A clot the size of an egg or larger should be weighed and findings reported to the physician or midwife (Suplee et al., 2016), as large clots can interfere with uterine involution. ● 1 g in weight equals 1 mL of blood loss. ● Clots should be examined for the presence of tissue. ● Retained placental tissue can interfere with uterine involution and lead to excessive bleeding (Hobel & Lamb, 2016). ● Assess for color of lochia. Initial lochia for the first 3 days is rubra, which is red and bloody. The next stage of lochia is serosa, which is pink or brown. The final stage is alba, which is clear or whitish. ● Assess for odor. Lochia has a fleshy odor and smells similar to menstrual blood. Expected assessment findings are further described in

nursing actions of the immune system

● Assess temperature: ● Every 15 minutes for the first hour. ● Every 30 minutes for the second hour. ● Every 4 hours for the next 22 hours. ● Every shift after the first 24 hours or as stated in hospital/unit protocols. ● Rationale: Assessing the postpartum patient's temperature allows health care providers to monitor for complications such as infection. ● For temperature elevations of less than 100.4°F (38°C) during the first 24 hours postbirth: ● Encourage the woman to drink 8 to 10 glasses of fluid, or at least 64 ounces a day (James, 2014). ● Promote relaxation and rest ● Reassess 1 hour after intervention ● Rationale: Slight temperature elevations during the first 24 hours postpartum are likely associated with dehydration (Whitmer, 2011). ● For temperature elevations 100.4°F (38°C) or higher after 24 hours postbirth: ● Encourage the woman to drink a minimum of 10 glasses of fluids a day (James, 2014). ● Notify the physician or midwife of the elevated temperature and anticipate further evaluation. Notify the nursery of the maternal temperature elevation (James, 2014). ● Rationale: A temperature of 100.4°F (38°C) on two different occasions after the first 24 hours postdelivery is a sign of infection (James, 2014). ● Administer rubella vaccine as indicated. ● Administer other needed vaccines as ordered. ● Administer Rho(D) immune globulin (Rhophylac or RhoGAM) as indicated. ● Document findings and interventions.

nursing actions for the urinary system

● Assist the woman to the bathroom and encourage her to void within 2 to 4 hours postbirth. ● Rationale: Early voiding decreases the risk of cystitis and prevents bladder distention, which could lead to uterine atony and postpartum hemorrhage (James, 2014). ● Assess for urinary disturbances. ● Measure voidings postbirth. The woman should be able to void at least 300 cc within 2 to 4 hours of delivery. ● Rationale: Various birth-related factors, such as the stretching of the urethra, displacement of the bladder, birth trauma-associated neural dysfunction, and anesthesia, may interfere with the return of urinary function. Rapid filling of the bladder associated with the administration of IV fluids during labor and delivery and postpartum diuresis can lead to overdistention of the bladder (James, 2014). Measuring voidings allows the nurse to identify inadequate output and problems with urinary elimination. ● If voiding is less than 150 mL, the nurse must palpate for bladder distention, as this is indicative of urinary retention. Signs of bladder distention include uterine atony, displacement of the uterus above the umbilicus to the right, increased lochia, and fullness in the suprapubic area (James, 2014). Incomplete emptying of the bladder can lead to uterine atony and postpartum hemorrhage. Urinary retention may also lead to cystitis. ● A bladder scanner using ultrasound technology may be used to assess for urinary retention or to measure bladder residual volume after a void of less than 150 mL (Buchanan & Beckmann, 2014). ● If the woman is unable to spontaneously void and has an over-distended bladder postbirth, she will need to be catheterized (Cunningham et al., 2014; James, 2014; Smith, 2018). An indwelling urinary catheter left in place for 24 hours is recommended when inability to void is related to edema (Cunningham et al., 2014; Smith, 2018). ● A straight or "in and out" catheterization may be done if there is little or no edema present and repeated catheterizations are not needed. ● An integrative method when a woman is unable to void is the use of peppermint oil. That entails saturating a cotton ball with peppermint oil and placing it in the "hat" (urine-collection container) with a small amount of water and placing the "hat" on the toilet. Instruct the woman to sit on the toilet. The vapors of the peppermint oil have a relaxing effect on the urinary sphincter. ● The woman should be able to void within 2 to 4 hours of delivery. ● Rationale: After 24 hours, edema associated with trauma of the bladder and urethra related to birth should decrease (James, 2014). ● Assess for frequency, urgency, and burning on urination. ● Notify the physician or midwife if the patient reports frequency, urgency, and/or burning on urination. ● Rationale: These are signs of possible cystitis. ● Expected assessment findings: ● The woman spontaneously voids within 2 to 4 hours postbirth. ● Each voiding is at least 300 mL. ● The woman does not experience frequency, urgency, and burning on urination. ● Instruct the woman to increase fluid intake to a minimum of 10 glasses per day. ● Document findings and interventions

Venous Thromboembolic Disease

● Begin ambulation after symptoms dissipate (Cunningham et al., 2014). ● Administer elastic stockings. ● Manage pain, administering pain medication as needed. ● Teach woman how to administer heparin subcutaneously to her abdomen. ● Instruct woman to report side effects such as bleeding gums, nosebleeds, easy bruising, or excessive trauma at injection site. ● Venous thromboembolism bundle is discussed in detail in Chapter 7. ● Anticoagulation therapy is required for women experiencing a DVT during pregnancy with heparin compounds titrated to achieve a PTT of 1.5 to 2.5 times control values. IV anticoagulation should be maintained for at least 5 to 7 days, after which treatment is converted to subcutaneous heparin (Cunningham et al., 2014). ● Early reviews concluded that low-molecular-weight heparins (LMWH) are safe and effective for use throughout pregnancy. ACOG concluded that risks associated with LMWH use were rare and that no cause-and-effect relationship has been established between LMWH and congenital anomalies or maternal hemorrhage (Cunningham et al., 2014). ● Treatment of PE is to stabilize a woman with a life-threatening PE and transfer to ICU. Thromboembolitic therapy and catheter or surgical embolectomy may be done.

patient education for the gi system

● Instruct the woman to increase fluid intake and increase fiber and roughage in diet to decrease risk of constipation. ● Provide nutritional education. This is especially important for lactating women and women who had a cesarean birth. Women who are breastfeeding need to increase caloric intake by 500 to 1,000 calories a day (James, 2014). ● Encourage the woman to ambulate to increase GI motility and decrease risk of gas pains. ● Instruct the woman to increase fluid intake to a minimum of 10 glasses per day.

DISCHARGE TEACHING

● Signs of complications that need to be reported to the physician or midwife: ● Heavy lochia (saturating a pad in 1 hour) indicates possible secondary postpartum hemorrhage (James, 2014). ● The return of bright red, heavy bleeding after lochia has diminished or that becomes serosa or alba, or the passage of clots the size of an egg or larger indicates possible secondary postpartum hemorrhage (Suplee, Klepple, Santa-Donato, & Bingham, 2016). ● Foul-smelling lochia; indicates possible infection. ● Increased temperature (100.4°F [38°C] or higher); indicates possible infection. ● Pelvic or abdominal tenderness/pain; indicates possible infection. ● Frequency, urgency, or burning on urination; indicates possible cystitis. ● Unilateral breast tenderness, warm reddened area; chills and fever; indicates possible mastitis, which often occurs 3 to 4 weeks after delivery (James, 2014). ● Blurry vision, severe headaches, epigastric abdominal pain, fluid retention; may be associated with preeclampsia (Suplee, Kleppel, Santa-Donato, et al., 2016). ● Leg pain, swelling, redness may indicate venous thrombosis. Chest pain and difficulty breathing may be associated with pulmonary embolism (Suplee, Kleppel, Santa-Donato, et al., 2016). ● Thoughts of harming infant or self, difficulty caring for self and/or infant, difficulty sleeping or sleeping too much, and persistent feelings of depression and sadness are associated with postpartum depression (Suplee, Kleppel, Santa-Donato, et al., 2016). ● Expected physical changes ● Uterine involution, afterpains, progression of lochia ● Breast changes, engorgement ● Diaphoresis and diuresis ● Weight loss ● Women can expect to lose approximately 12 pounds immediately after delivery, and an additional 5 to 8 pounds due to fluid losses associated with uterine involution and diuresis (Cunningham et al., 2014). ● Self-care ● Hygiene ● Perineal care, continue to change pad frequently and use peri-bottle until lochia has stopped ● Breast care for lactating and nonlactating women ● Pharmacological and nonpharmacological pain control measures

Maternal Mortality

•Death from complications of pregnancy/childbirth up to 1 year after birth •Current rate: we are not hitting our mark: we need to be doing better •Prevention: Healthy People 2020 •Objective: reduce the rate of maternal mortality •Baseline: 12.7 maternal deaths per 100,000 live births •Target: 11.4 maternal deaths per 100,000