Exam 2

Afterbirth Contractions

"Afterpains" "Afterbirth Contractions" *Uterus contracting down-returning to pre-pregnant state (2-5 days to 1 week) *Menstrual-like cramping/contractions *Increased with full bladder *Increased with breastfeeding -analgesics 30 mins before breastfeeding *Increased with parity *Increased with LGA newborn

Reva Rubin's 3 Phases

*Taking-in phase *Taking-hold phase *Letting-go phase

Progesterone

A hormone produced by the ovaries which acts with estrogen to bring about the menstral cycle.

Oxytocin

A hormone released by the posterior pituitary that stimulates uterine contractions during childbirth and milk ejection during breastfeeding.

Seven hours ago, a multigravida woman gave birth to a 4133-g male infant. She has voided once and calls for a nurse to check because she states that she feels "really wet" now. Upon examination, her perineal pad is saturated. The immediate nursing action is to:

assess and massage the fundus

Temperature

Some woman experince slight fever up to 100.4 F (38 c) for the first 24 hours as a result of dehydration.

Thromboembolism

Three most common types *Superficial thrombosis- usually lower leg- d/t positioning in labor *Deep vein thrombosis-deep vein from foot to calf, to thighs or pelvis, both can dislodge/migrate to lungs causing pulmonary embolism. *Pulmonary embolism- can be fatal if clot obstructs lung circulation

Lochia

Tissue and blood discharge from uterus (C/S or vag) *Lochia rubra- dark red, blood-tinged discharged including shreds of tissue and decidua days 1- 3-4 postpartum *Lochia serosa- pale pinkish to brownish discharge; days 4 to 10 days after postpartum *Lochia alba- thicker, whitish-yellowish creamy or colorless discharge with leukocytes and degenerated cells; last from days 10-14 postpartum (may continue for several weeks) ***Less lochia with C/S in 1st 24 hrs

Uterine Atony

failure of the uterus to contract and retract after birth

A client appears to be resting comfortably 12 hours after giving birth to her first child. In contrast, she labored for more than 24 hours, the primary care provider had to use forceps to deliver the baby, and she had multiple vaginal examinations during labor. Based on this information what postpartum complication is the client at risk for developing?

infection There are many risk factors for developing a postpartum infection: operative procedures (e.g., forceps, cesarean section, vacuum extraction), history of diabetes, prolonged labor (longer than 24 hours), use of Foley catheter, anemia, multiple vaginal examinations during labor, prolonged rupture of membranes, manual extraction of placenta, and HIV.

Prolactin

stimulates milk production

Physical Assessment (cont'd)

*Abdomen-soft, not distended, no epigastric pain *Uterus (after emptying bladder) -fundus-firmness, height, midline -gental massage is boggy, amt/color lochia *Bowl sounds-diminished but not absent *Rectal Area-hemorrhoids-sitz, cool, witch hazel pads *Bladder- keep empty or catheterize *Breast- engorgement, nipple tenderness

Postpartum Hemorrhage

*Bloos loss -norms: 150-300 ml vaginal 500-1000ml cesarean delivery -excessive blood loss >500ml vaginal >10000 cesarean *any amount of bleeding that places the mother in hemodynamic jeopardy *most common cause is Uterine Atony (uterine muscle fails to contract adequately to compress blood vessels)

Cesarean Delivery Assessment

*C/S assessment (same with few additions) *abdominal dressing- check for signs of bleeding, drainage, bruising *Lung sounds- C &DB (cough and deep breath) *Post anesthesia/epidural/spinal assessment -return of sensation/leg movement/ability to support own weight *emotional adjustments- unexpected surgery

Lactation (continued)

*Engorgement -Process of swelling of the breast tissue due to an increase in blood and lymph supply as a precursor to lactation -also seen with incomplete emptying of the breast -leaking common whether BF or not -Frequent emptying, warm showers and compresses before feeding, cool compress between feedings, if breast feeding -Tight supportive bra, cool packs, analgesics, avoidance of breast stimulation (no pumping) if not breast-feeding

Two days after giving birth, a client is to receive Rho(D) immune globulin. The client asks the nurse why this is necessary. The most appropriate response from the nurse is?

"Rho(D) immune globulin suppresses antibody formation in a woman with Rh-negative blood who gave birth to a baby with Rh-positive blood."

Assessment Acronym

(B)reast (size, contour, engorgement) (U)terus (height of fundus, firmness) (B)ladder (voiding, bladder emptying) (B)owels (bowel sounds, distention) (L)ochia (amount, color, odor) (E)pisiotomy and perineum (lacerations, hematoma) (H)emorrhoids (E)extremities (E)motional status

Physical Assessment

**Immediate Postpartum Assessment *Gather Data -receive detailed report -review chart -L&D report -Last pain meds -patient history including prenatal

Postpartum Infections

*Fever>38 degrees c or 100.4 F AFTER 1sr 24 hours *Organisms usually those of normal vaginal flora (aerobic and anaerovic) *Metritis- infection of endometrium, decidua, and adjacent myometrium *wound infections *Urinary tract infections *Mastitis- infection of the breast

Subinvolution

Failure of uterus to pre-pregnant state at rate expected *Involution can be slowed by: -Full bladder -Prolonged labor -Rapid delivery -Grand multiparity -Pelvic infection -Incomplete expulsion of placenta/membranes

Estrogen

Female sex hormone

Mastitis

Flu-like symptoms, malaise, low grade fever, chills, tender, hot, red, painful area on one breast, inflammation of breast area, breast tenderness, cracking of skin or around nipple or areola, breast distention with milk.

Metritis

Lower abdominal tenderness or pain on one or both sides. Temp elevation (>38c), foul smelling lochia, anorexia, nausea, fatigue and lethargy, leukocyotis and elevated SED rate

UTI

Urgency, frequency, dysuria, flank pain, low-grade fever, urinary retention, hematuria, urine positive for nitrates, cloudy urine with strong odor

Wound Infection

Weeping serosanguineous or purulent drainage, edema, erythema, separation of or unapproximated wound edges, tenderness, discomfort to the site, maternal fever. Elevated white blood cell count.

Involution

*Immediately after birth uterus is: -half-way b/w symphysis/umbilicus -firm, grapefruit size -if boggy, gently massage/empty bladder *Within 10-12 hrs. moves 1-2 cm/FB even or above umbilicus *24 hours even to about 1 FB below umbilicus *Involution 1-2 FB a day *10-14 days decreases to at or below symphysis pubis

Negative Behaviors

*Infant -Feeds poorly, regurgitates often; cries for long periods, colicky and inconsolable; shows flat affect, rarely smiles even when prompt; resist holding and closeness; sleeps with eyes closed most of the time; stiffens body when held; is unresponsive to parents; doesn't pay attention to parents' faces. *Parent -Expresses disappointment or displeasure in infant; fails to 'explore' infants visually or physically; fails to claim infant as part of family; avoids caring for infant; finds excuses not to hold infant close; as negative self-concept; appears uninterested in having infant in room; frequently asks to have infant taken back to nursery to be cared for; assigns negative attributes to infant and calls infant inappropriate names (e.g. frog, monkey, tadpole)

Reproductive System Adaptions

*Uterus *Involution -contraction of muscle fibers -catabolism, which shrinks enlarged, individual myoetrial cells -regeneration of uterine epithelium (placental site heals without scarring -lochia: rubra, serosa, alba

Nursing Assessment

*Vital signs including pain -temp -pulse -resp -BP -pain *Administer ordered analgesics as ordered *Fundal height checks, lochia amount/# of pads -1st hr q 15 mins for 1 hr -q 30 mins in 2nd hr -q 4 hrs for 24 hrs -q 8 hrs until discharge

Physical Assessment Nurses Role

*Vital signs/ Pain Assessment *Fundus- firmness, height, location *Lochia- color, amount *LOC- especially post anesthesia *DTR-especially for post mag sulf *Respiratory-RR, breath sounds *Skin- temp and color *Apical pulse *IV-site *Intake and output *Homan's sign-modify

Urinary System Adaptation

*Voiding reflex diminished due to: -Edema -Hyperemia in the bladder -Diminished sensation of bladder pressure due to swelling, poor bladder tone, and numbing effects of regional anesthesia used during labor. -Swelling or bruising of tissue around urethra/perineum after delivery (including hematoma)

Signs of bleeding from unrepaired lacerations

*continuous trickle from vagina *bleeding in spurts *bleeding in presence of contracted fundus

4th Stage of Labor

*first 1-4 hours after delivery of the placenta *crucial time for mom and bay *recovery from physical process of birth *time to begin getting acquainted **POSTPARTUM HEMORRHAGE** --most likely to occur now

Lochia (continued)

*odor distinctive, menstrual-like *foul odor could be infection *increased amount with physical exertion (first time standing and breastfeeding) *small clots common, but if large (golf ball size) or a continuous trickle of lochia- MD/CNM should be notified-abnormal

Postpartum;Nursing Interventions (continued)

*promoting activity, rest, and exercise -early ambulation -rest periods -exercise program; recommended exercises; kegel exercises *assisting with self-care measures *ensuring safety *counseling about sexuality and contraception

Postpartum: Nursing Interventions (continued),,again

*promoting nutrition -general recommendations -needs for breast-feeding woman *supporting choice of newborn feeding method -assist with breast or bottle feeding

Postpartum: Nursing Interventions

*provide optimal cultural care *promoting comfort -cold and heat applications -topical preparations -analgesics *Assisting with elimination -promoting voiding and bowl elimination **resume intercourse when bright red blood ceases, episiotomy heals, cesarean incision heals (3-6) wks -use BC-ovulate before 1st period

Hematoma Formation

*signs of hematomas develoing in perineum **Intense perineal pain *Swelling and blue-black discoloration on perineum *Pallor, tachycardia, hypotension (great blood loss)(pre shock) *Feeling of fullness, pressure in vagina, urethra, and or/bladder *Possible urinary retention, uterine displacement

Signs of Bleeding from Uterine Atony

*soft, boggy uterus, usually above umbilicus *fundus does not firm up with massage

Additional Reproductive System Adaptions

*Cervix- spongy; now appearing as jagged slit-like opening, heals 6 weeks *Vagina-edematous (edema), walls thin. dry, eventual thickening and return of rugae, 3 weeks *Perineum-edema, ecchymosis possible inc. tenderness with episiotomy/lacerations-up to 1 week, hemorrhoids. Ice 1st 24 hrs, analgesics-report excessive pain MD/CNM

Postpartum Hemorrhage (PPH)

*Excessive bleeding after childbirth; traditionally defined as a loss of 500 ml or more after a vaginal birth and 1000 ml after a cesarean birth ***Uterine Atony is the most common cause of postpartum hemorrhage *Lacerations of birth canal/episiotomy *Precipitous birth or trauma during birth *Retained placental fragments *Overdistended uterus-large baby *Full bladder *Polyhydramnios (large amount of amniotic fluid *Grand multiparity (>7) *Induced labor *Previous history of hemorrhage *Coagulation disorders *Hematomas of the vulva, vagina, or sub peritoneal areas

Urinary System Adaptations

*Glomerular filtration increases *Diuresis- up to 3000 cc/day to rid body of 2-3 liters of pregnancy fluids (very common first 24 hours) *Greater in patients with: -Hypertension -Gestational hypertension -Pre-eclampsia -Diabetics -Large amount of fluids during labor *Urine Glucose, creatinine, BUN norm. after 7 days

Hematological System

*Hct may rise- due to hemodilution in pregnancy- then plasma loss in delivery *WBC count elevated (12,00 and up to 25000) *Difficult to use white count for determination of infection *Low HGB<10 mg/dl- may be sign of excessive blood loss *Blood-clotting factors elevated; increases risk of thromboembolism *SVD-150-300cc average blood loss *C/S-500-1000cc average blood loss

Taking-in phase

*Immediately after birth to about 48 hrs. *When the client needs sleep, relieves the events of her birth experience, focused on self, assumes a passive role and dependence on others for care, asking for help on simplest task, self centered, talkative, explores with fingertip touching

Positive Behaviors

*Infant -smiles; is alert; demonstrates strong grasp reflex to hold parents finger; sucks well, feeds easily; enjoys being held close; makes eye-to-eye contact; follows parent's face; appears facially appealing; is consolable when crying. *Parent -Makes direct eye contact; assumes en face position when holding infant; claims infant as a family member, pointing out common features; expresses pride in infant; assigns meaning to infants actions; smiles and gazes at infant; touches infant, progressing from fingertips to holding; names infant; request to be close to infant as much as allowed; speaks positively about infant.

Ovulation and return of Menstration

*Interplay of hormones:estrogen, progesterone, prolactin, and oxytocin *Non lactating womean- return of menstruation 7- 9 weeks after birth *Lactating women-return dependent on breast feeding frequency and duration; anywhere from 2-18 months

Musculoskeletal Adaptations

*Joints- symphysis pubis soreness *Fatigue levels *Abdominal muscle tone- 6 weeks *Pelvic muscle tone return 3-6 weeks

Psychological Adaptation: Nursing Role

*Nurse needs to recognize that new mothers and fathers need reassurance and support. *Nurses need to allow mothers to care for herself and infant. *Nurses should observe mother's skill and intervene only when needed. This increases mother's confidence as does positive verbal input. *First time mothers need to be confident in skills before taking newborn home.

Postpartum Hemorrhage: Nursing

*Nursing Assessment -risk factors -uterine tone; vaginal bleeding *Nursing Management -fundal massage; pad count, empty bladder -administration of uterotonics -fluid administration -monitoring for signs and symptoms of shock

Thromboembolic Conditions: Nursing

*Nursing Assessment -risk factors-OCP's, smoking, prolonged standing, hx of thrombosis, thrombophlebitis, or endometritis, varicosities -signs ad symptoms- pain or tenderness in lower extremities, esp. calf w/ ambulation, swelling, Homans (no longer definitive dx) *Nursing Managment -prevention- i.e, early ambulation -adequate circulation: NSAIDs, bed rest, antiembolism stockings, anticoagulants therapy (heprin): emergency measures for pulmonary embolism -education

Postpartum Infections: Nursing Management

*Nursing Management -infection prevention aseptic technique; hand-washing; perineal hygiene screening of visitors -administration of antibiotics; wound care -client teaching *continue antibiotic therapy as prescribed, even if you feel better *check temp everyday and report any S&S of infection *practice good prevention-i.e., good hand washing, wipe front to back and remove and place pad *good nutrition, hydration, adequate rest

GI System Adaptations

*Patients often hungry and thirsty after work of labor *Relief of pressure on organs *Bowel sluggishness due to: -Decreased intestinal muscle tone -Hormonal levels -Pre-labor diarrhea -Lack of food intake in labor -Analgesics/Anesthesia *Often no BM for 2-3 days -D/T episiotomy/lacerations/tenderness -often painful-analgesics

Integumentary System Adaptions

*Pigmentation- Chlosma/linea nigra regress *Stretch marks-from red to silvery, never disapear *Spider nevi-fade *Diaphoresis-increase perspiration "nightsweats"

Respiratory and Endocrine System Adaptations

*Respiratory System- returns to pre-pregnant -respiratory rate -diaphragm position *Endocrine System -Estrogen and Progesterone levels (Drop) Estrogen is at it's lowest during the week after birth. Levels will remain decreased with breast-feeing mothers and will start to increase with non breast-feeing mothers. -Placental hormones (Drop) -Prolactin levels decline for non breast-feeding mothers and remain high with breast-feeding mothers. -Gestational diabetes (returns to normal state)

Lactation

*Result of interaction of progesterone, estrogen, prolactin, and oxytocin *Secretion of milk by the breast *Colostrum available before and after birth *Mature breast milk by 2-5 days *Valuable immune support

Taking-hold phase

*Teach about baby in this phase* *Second stage of maternal adaption, characterized by dependent and independent maternal behavior. *Starts 2-3 days PP and last 7-10 days *Less focused on physical discomforts, increased independence on self-care, strong interest in caring for the neonate thats often accompanied by a lack of confidence about her ability to provide care. *Still need nurturing and acceptance by others *Eagerness and ready to learn and practice handling of physical discomforts and emotional changes, possible experience with "blues". *After C/S may have feelings of disappointment, inadequacy, loss of "dream birth"

Nurse's Role

*Teach/demonstrate -breast care measurments -perineal care measurements -measures to prevent bladder infection -measures to enhance healing and maintain resistance to infection

Postpartum infections: Nursing

*Therapeutic Managment -broad-spectrum antibiotics for metritis -wound care for wound infections -fluids and antibiotics for UTI's -Breast emptying and antibiotics for mastitis *Nursing Assessment -risk factors -signs and symptoms

Letting-go phase

*Third role of maternal adaption to parenthood and definition of new role as a parent and caregiver. *Abandonment of fantasized image of neonate and acceptance of real image. Recognition of neonate as a separate entity. Assumption of responsibility and care of neonate. *Focus on forward movement of family, reassertion of relationship with partner, resumption of sexual intimacy, "letting go" is a lifelong process.

Thromboembolic Conditions

*Thrombosis- blood clot within a blood vessel can cause inflamation of blood vessel lining, which can lead to thromboembolism *Thromboembolism- obstruction of a blood vessel by clot, carried by the circulation from the site of origin -prolonged bed rest (long induction), prolonged pushing, holding legs under knees *Pathophysiology -venous stasis -injury to innermost layer of blood vessel -hypercoagulation

Bonding and Attachment

*Transition to parenthood -stages-lifelong process -factors affecting attachment: parent's background, infant, care practices. *Critical attributes of bonding/attachment -**En face, full hand stroking, calling pet names** -Proximity, reciprocity, commitment -Positive and negative attachment behaviors

A nurse finds the uterus of a postpartum woman to be boggy and somewhat relaxed. This a sign of which condition?

*Uterine Atony *The uterus in a postpartum client should be midline and firm. A boggy or relaxed uterus signifies uterine atony, which can predispose the woman to hemorrhage.