Exam 4 review

PERINEUM

-Assess for hemorrhoids, episiotomy, laceration, bruised, edematous -Ice pack - first 24 hours (vasoconstriction) -Sitz baths—warm water (vasodilate) Hazel pads, anesthetic spray, peri bottle -Episiotomy - pain, strain, BM, tear sutures Fl, walking, fiber, colace -Episiotomy or laceration healing may take 4-6 months in the absence of complications (hematoma and infections) -KEGELS to improve pelvic floor tone

PPD NURSING INTERVENTIONS

-Assess for risk factors/history of PPD -Assist in coping with changes -High risk moms: educate, referral for counseling -Stress that it's common to need help postpartum -EPDS: screening tool used at 2wk check-up

Wound Infections

-C-section incisions, episiotomy site, laceration site, epidural site -High WBC -High fever -REEDA: redness, edema, ecchymosis, drainage, approximation

LACTATION

-Colostrum - first milk -Clear/yellow, high in nutrients, proteins, & antibodies, sweeter, helps babies latch on -Prolactin increases at term with decrease of estrogen/progesterone -If mom does not want to breastfeed: -Wear supportive bra -Ice when engorgement happens -DO NOT stimulate - will make more milk; analgesics to help with pain

Blues:

-Day 3-5 -Resolve by day 10-2wk -Sleep helps -Affects 50-90% **KNOW TIME FRAMES: IF LASTS LONGER THAN 2WK+ SEEK HELP

COMMON POSTPARTUM DISORDERS

-Hemorrhage -Infection -Thromboembolic disease -Postpartum affective disorder (depression, psychosis)

Baby blues

-Mild depressive symptoms, anxiety irritability, mood swings, tearfulness, increased sensitivity, fatigue -Hormones fluctuating -No sleep - sleep helps!!!! -Peaks 4-5 days end day 10

THROMBOEMBOLIC CONDITIONS: ASSESSMENT signs and symptoms DVT

-Red -Pain -Tender -Calf discomfort -Swelling -Pedal edema -+ Homans Sign

Vagina

-Returns to normal at end of postpartum (6wk) -Normal mucus production & thickening of mucosa return with ovulation -Lactation amenorrhea - no period r/t breastfeeding, not a good contraceptive -Dyspareunia (painful sex) may occur until menstruation returns -Water-soluble lubricants

LACTATION/FEEDING

-Support woman's choice on method of feeding -Breast contraindicated: HIV, drugs, probs w/ mom or baby -When discussing breast feeding -Stimulation encourages milk production -Nipple shields if nipples are cracked -Breast pads for leaking -PUMP to stimulate production if they cannot put baby to breast -Consult with lactation consultant -Avoid soap on breast

Disseminated intravascular coagulation (DIC)

-Widespread clot formation -Too many clots formed because clot system is abnormally activated

Letting-go phase

-Woman reestablishes relationships with others -Two separate roles; adapting parental role and life changes that now have to include nugget -BAM (becoming a mother)

Thrombin

-Coagulopathy (preexisting or acquired) -Bleeding continues without any cause -Prolonged PT and PTT times -Von Willebrand's disease= prolonged bleeding time -Platelets aren't sticking -Give DDAVP - enhances levels of factor 7 -Low Na levels - risk of seizures -Nosebleed and hematoma are common

ENDOCRINE

-Estrogen, progesterone, placental hormones - decrease rapidly -Drop as soon as placenta is delivered -Prolactin levels remain high for breastfeeding -If not breastfeeding - will decrease in 2wk

FUNDAL CHECKS

-Fundus goes down one finger breath each day of postpartum -U/U after birth - @ umbilicus at 24hr -Typically descends from level of umbilicus at a rate of 1 cm/day -1/U—one above umbilicus -U/1—one below umbilicus -Day 10 - can't feel/palpate

CAUSES OF PPH

-Most common cause: uterine atony (doesn't clamp down) -Lochia red with boggy uterus -Lacerations Bright red blood with firm uterus -Episiotomy Slow, steady bleed -Retained placental fragments (placenta accreta, previa) -Uterine inversion Prolapse of fundus into uterus "turned inside out" -Coagulation disorders -Hematomas of the vulva, vagina, or subperitoneal areas

GI SYSTEM

-NPO during labor -Bowels sluggish following birth regardless of vaginal or cesarean birth -GI usually returns to normal quickly -Bowel sounds can be hypo when listening at first -Decreased peristalsis due to analgesics, surgery, diminished intra-abd pressure, low-fiber diet, insufficient fluid intake, diminished muscle tone -Constipation is common -Fear of using bathroom for BM following vaginal birth -Encourage food, fiber, fluid, walking -Stool softener can be ordered

THROMBOEMBOLIC CONDITIONS: ASSESSMENT risk factors

-Smoking -Bed rest -Oral contraceptives before pregnancy -Prior history -Current varicosity -Job where they're on their feet -Obesity -Diabetes -Adv maternal age (35+) -C-section -Varicose veins

Breast-feeding

-Freq feeds q2-3h -Manual expression before feeds to soften breast -Feed on first breast until it softens before switching

ITP

-Low platelets—increase risk of PPH -Petechia rash -Give steroids

Risk for Hemorrhage (PPH)

-Placenta issues -Uterine atony -Precipitous labor (less than 3 hours) -Any labor induction/augmentation -Placenta previa/abruption -Operative procedures -Prolonged 3rd stage -Mult. gestations -Stretched uterus

UTI

-Urinary freq -Urgency -Flank pain -Urinary retention -Low grade temp -Blood in urine (hematuria) -Cloudy/smelly urine -Can be from not completely emptying bladder

ENGROSSMENT: PARTNER PSYCHOLOGIC ADAPTATION

-Visual awareness of the newborn -Tactile awareness of the newborn -Perception of the newborn as perfect -Strong attraction to the newborn -Awareness of distinct features of the newborn -Extreme elation by the father -Increased sense of self-esteem -Dad doesn't go through any physical changes like mom does -He goes from being a partner/support system to a parent

WHILE ASSESSING A PRIMIPAROUS CLIENT 8 HOURS AFTER CHILDBIRTH, THE NURSE INSPECTS THE EPISIOTOMY SITE, FINDING IT EDEMATOUS AND SLIGHTLY REDDENED. WHICH INTERPRETATION BY THE NURSE IS MOST APPROPRIATE? A. The client needs application of an ice pack. B. The episiotomy site is probably infected. C. A hematoma will likely develop. D. The client has had a repair of a vaginal laceration.

A. The client needs application of an ice pack. Rationale An episiotomy that is edematous and slightly reddened 8 hours after childbirth is normal. Therefore, the nurse should offer the client an ice pack to provide some relief from the perineal pain for the first 24 hours. An infection is present if greenish, purulent drainage is observed from the site. The edema and discoloration of the episiotomy at this time after childbirth are normal and do not indicate that a hematoma is likely to develop. A laceration when repaired should appear intact with edges well-approximated, clean, and dry.

Alba

white - 2-6wk Consists of leukocytes, decidual tissue, and reduced fluid content

Depression:

-20% women, 60% adolescent women -Symp: restless, worthless, guilty, crying a lot -Gets worse over time -Gradual onset

BUBBLE-EET: EXTREMITIES

-Assess for blood clots and PE -3 factors predispose women: stasis, altered coag, localized vascular damage -They have hypercoagulability—protects mom from blood loss during pregnancy -Check calves for: redness/tenderness and tightness when walking -Dorsiflex foot and note pain (Homans sign) -Encourage ambulation, SCDs, elevate legs -Doppler if worried for clots -Chest pain, SOB

POSTPARTUM HEMORRHAGE (PPH)

-Blood Loss -500mL+ following a vaginal birth -1,000mL+ following a cesarean birth -Most common cause: uterine atony -Early Postpartum Hemorrhage Occurs within 24 hours of birth -Late Postpartum Hemorrhage Occurs 24 hours to 6 weeks after birth -Best practice - WEIGH drapes, laps, sponges

Taking-hold phase

-Dependent and independent maternal behavior -2-3 days PP and can last for a few weeks, more autonomy/self-confidence to take care of baby—wants to do it independently -Still requires reassurance

Cervix

-External: os never goes back to pre-pregnancy state -Before kids - circular -After kids - slit-like, never fully closes -Internal: return to normal after 2wk

Coagulation

-Pooling and stasis of blood in the lower limbs place women at risk for blood clots -2-3 wks PP stays elevated - still hypercoagulable -Blood clots! -SCDs, walk. Fl, s/s to watch for, DVT, PE, chest pain, SOB, dyspnea -Greater risk with history of smoking, obesity, immobility (c-section)

PP DANGER SIGNS

-Temp above 100.4 - infection -Foul smelling lochia - infection -Lochia goes bright red - laceration -Excessive bleeding/large clots/more saturated pads - hemorrhage -Calf pain, swell, red, warm - DVT -After day 10 still depressed - PPD -Swelling/pain/discharge from episiotomy, c-section suture - infection -Hx of pre-e🡪 headache/vision changes/dizzy SOB, chest pain: PE -Dysuria, burning, or incomplete emptying of bladder - UTI

THROMBOEMBOLIC CONDITIONS

-Three most common thromboembolic conditions in PP period: -Superficial venous thrombosis (aka thrombophlebitis) Usually confined to the saphenous vein in lower leg Skin over vein becomes swollen, red, painful Lithotomy pos for too long -Deep vein thrombosis Foot to calf or thigh to pelvis Most common condition -Pulmonary embolism Leading cause of pregnancy related deaths in US Clot in pulmonary artery - SOB, chest pain, dyspnea

RESPIRATORY SYSTEM

-Tidal volume, minute volume, vital capacity, and functional residual capacity return to prepregnant values within 1 to 3 weeks of birth -Anatomic changes reside quickly -Diaphragm returns to its usual position - baby no longer pushing on diaphragm ! -Mom can breathe better! -RR will be WNL—may be lower if pain medication is administered -Normal RR 16-20

Blood Volume

-Vaginal - 500mL blood loss -C-section - 1000mL blood loss -More than that = hemorrhage risk!!

DURING THE FIRST HOUR AFTER A PRECIPITOUS BIRTH, THE NURSE SHOULD MONITOR A MULTIPAROUS CLIENT FOR SIGNS AND SYMPTOMS OF WHICH COMPLICATION? A. postpartum "blues" B. uterine atony C. intrauterine infection D. urinary tract infection

B. uterine atony Rationale Because birth occurs so rapidly and the fetus is propelled quickly through the birth canal, the major complication of a precipitous birth is a boggy fundus, or uterine atony. The neonate should be put to the breast, if the mother permits, to allow for the release of natural oxytocin. In a hospital setting, the health care provider (HCP) will probably prescribe administration of oxytocin. The nurse should gently massage the fundus to ensure that it is firm.

Serosa

dark brown/pink - 10 days Leukocytes, decidual tissue, RBC, and serous fluid

Rubra

dark red - 3-4 days Deep-red mix of mucus, tissue debris, and blood

Tissue

retained placenta and clots

BUBBLE-EET: BOWELS

-Assess: Active/hypo, soft/distended, flatus, BM, sounds -Hypoactive/slow bowel sounds from anesthesia -Normal assessment findings are active bowel sounds, passing gas, and nondistended abd -Peristalsis can decrease from elevated progesterone—may not have BM 1-3 days PP -Fear of BM if there was an episiotomy or laceration—they will NOT tear -Stool softeners -Encourage ambulation, increase fluids, and a high fiber diet

BUBBLE-EET: BLADDER

-Assess: Non/distended, voiding?, foley?, color/output -Check for distention/signs of UTI -Low output - hemorrhage! -Cannot always feel sensation of full bladder; may need to straight cath -Do not take out more than 1000mL at a time when straight cathing -You can bladder scan if they have not voided or after a straight cath to see if there is anything left -Signs of UTI: -Cloudy urine, painful, frequency

BUBBLE-EET: LOCHIA

-Assess: clots, rubria/serosa/alba, scant/small/mod/large -When pressing down on fundus, assess peripad to see the amt/color lochia being expelled -Scant (1-2 inch, 10 mL loss) -Light/small ( 4 inch, 10-25 mL loss) -Moderate (4-6 inches, 25-50 mL loss) -Large (saturating pad within 1 hr of changing—sign of hemorrhage) -If excessive bleeding occurs (more than 1 saturated pad/hr) = massage the fundus!! -Make sure you note color (in hospital it should be rubra) -It should NOT have an odor

BUBBLE-EET: EMOTIONAL STATUS

-Assess: eye contact, touch, participates in care -Is bonding/attachment present -Bonding: close emotional attraction to a newborn by parents develops during first 30-60 mins after birth -Continuation of relationship that began during pregnancy -Infant is quiet, alert, and looking directly at holder -Erikson: trust vs mistrust

BUBBLE-EET: UTERUS

-Assess: firmness, pos, ht -Lay supine, make sure bladder has been emptied -After delivery (1-2 hrs), fundus should be midway to umbilicus -At 6-12 hours can be at umbilicus (@24h should def be at umbilicus) -NONPALABLE AT 10 DAY -Every day PP it should be one finger breadth under umbilicus -Make sure it is MIDLINE & firm -Feel top of uterus with one hand and use the other to stabilize the bottom -Boggy uterus= uterine atony

BUBBLE-EET: EPISIOTOMY

-Assess: lactations, hematoma, hemorrhoids -Usually have mom turn to side and bend the opposite leg (if on left side, bend right leg) -Hold buttocks and check incision -REEDA: Redness, edema, ecchymosis, approximation, drainage If anything is not within normal limits, call MD -4 degrees of laceration; 1st degree: skin and superficial structures above muscles 2nd degree: extends thru perineal muscles 3rd: extends thru anal sphincter muscle 4th degree: extends thru anterior rectal wall

BUBBLE-EET: BREASTS

-Assess: soft/filling/full, nipples, contour, engorged, breast/bottle -Did colostrum come in? -Are breasts soft and nontender? Engorged? -Breast or bottle? -If breast feeding, are nipples painful? -Any blistering, cracks? -May indicate that the baby is improperly positioned on the breast -Use light touch on moms who are not breast feeding -Palpate for nodules, masses/areas of warmth -Plugged duct that leads to mastitis

Risk for PP infection

-C-section -Difficult delivery -Hx of diabetes -Prolonged labor (over 24 hrs) -Foley -Multiple vaginal exams/vaginal monitoring -Prolonged ROM -Manual extraction of placenta

BUBBLE-EET: EPISIOTOMY

-Check for hematomas -Large, blueish skin with complaints of severe pain in the area of indictive pelvic of valvular hematomas Severe intractable pain, perineal discoloration and ecchymosis -Can have up to 250 mL of blood inside -Check for lacerations that may have not been picked up -Bright red blood -If you palpate fundus, it will be firm!!! -Epidural - assess insertion site -Can do ice/sitz bath, peri bottle, witch hazel, benzocaine numbing cream - depends on timeframe hot/cold

TEACHING TOPICS: PAIN/DISCOMFORT

-Cold - 1st 24h vasoconstrict, ice packs reduce swelling -Heat - after 24h, vasodilate, sitz bath, for healing -Peri bottle - squirt bottle to cleanse the perineum -Topical creams Benzocaine for pain Hemorrhoids - Witch hazel tucks Lanolin - nipple pain (remove before breastfeeding) -Analgesics Tylenol NSAIDS: ibuprofen Severe: oxy/codeine S/e: dizzy, lightheaded, n/v, sedation, constipation Drugs excreted in breastmilk -Rest for c-section Handout for c-section care. Saline wipe to clean incision -Abd binders for c-section—it splints incision and adds support

BREASTS

-During pregnancy -Inc levels of estrogen, progesterone stimulate breast duct proliferation & development -Each breast gains about 1lb in weight during pregnancy -Prolactin triggers synthesis/secretion of milk -Once placenta expelled -Progesterone and estrogen levels fall -Baby to breast - stimulate pituitary (prolactin & oxytocin) -Prolactin - Helps stimulate milk production & inhibit ovulation -Oxytocin - Helps stimulates milk let down & uterine contraction -Cycle - more stim = more milk

TYPICAL PP ASSESSMENT

-During the 1st hour: every 15 minutes -During the 2nd hour: every 30 minutes -During the first 24 hours: every 4 hours -After 24 hours: every 8 hours -Assessment will include: -Vitals -Physical (BUBBLE-EET) -Psychosocial -Keep in mind: Vag deliveries will spend (if complication free) 48h in hospital C-section will spend 3 days

Bonding

-Emotional attraction -To newborn by the parents that develops the first 30 to 60 minutes after birth -Unidirectional, from parent to infant -Vital component to attachment -What can affect bonding? NICU, birth defect, unplanned preg, birth experience (traumatic), parents as role models for them

DAD'S THREE STAGE ROLE DEVELOPMENT PROCESS

-Expectations They think about how life will be like with a newborn -Reality Expectations are not really realistic Feelings change from elation to sadness, ambivalence, jealousy, and frustration Feelings of ambivalence, frustration, male PP depression -Transition to mastery Take conscious control over "this is my life, this is my baby"

MATERNAL PSYCHOSOCIAL ADAPTATIONS: ATTACHMENT

-Formation of a relationship between a parent & newborn through a process of physical and emotional interactions -Assess for attachment: -Holding baby, looking at baby, talking to baby, has name for baby, interest in learning, baby in room -Early and sustained contact between newborns and parents - VITAL! -Skin-to-skin and rooming in is encouraged -Baby is alert the first 30min after birth (reactive phase)—best time to breast feed! -En face position (face-to-face) -Nurses play a crucial role is assisting with this process of attachment

NURSING MANAGEMENT

-Fundal massage; pad count -Administration of uterotonic drugs -Pitocin 20-40U in 1L IV- 1st line tx!!! -Methrogen 0.2mg IM (contraindicated in HTN) - NOT IV: can raise BP -Hemabate 0.25mg IM (contraindicated in asthma) -Misoprostol—stim contractions & controls bleeding (by helping to clamp down); never give undiluted as bolus injection -Fluids Inc blood volume -S/s of shock Low BP, high HR, decrease urine output, change in LOC, slow cap refill, low O2 sat, dizzy, anxious, cold, clammy

BOTTLE FEEDING MOMS

-If the mother is bottle feeding: -Wear tight supportive bra 24 hrs/day -Apply ice to breasts -Avoid sexual stimulation -Avoid manually expressing milk -Avoid exposure to warmth -Remember - the more you stimulate, the more it comes in!!!

Taking-in phase (24-48h after birth):

-Immediately after birth when the client needs others to meet her needs (passive role) and relives the birth process (talkative, excited) -Passive—mom relies on nurse for feeding, changing, and what's going on with baby

NUTRITION

-Increase fluids— especially if breast feeding -Increase diet by: -Cals - 500+/day 1st & 2nd mo lactation -Protein - 20+mg/day -Ca - 400+mg/dau -Iodine - 290mcg/day -Fl - 2-3+quarts/day (milk, O2, juice) - no pop!

URINARY SYSTEM

-Increased bladder capacity, swelling, bruising -Urine stasis - inc risk UTI -Epidural - decreases urine output -May not feel full bladder - straight cath ! -Puerperal diuresis - excessive fluid excretion after childbirth -Causes: large amts IV fluids, d/c Pitocin, buildup/retention of fl during pregnancy -Pitocin - antidiuretic property (causes mom to hold onto fl), won't diuresis as much until Pitocin d/c -Sweating a lot (while they shower - change sheets & gown!)

Mastitis

-Inflammation of the breast (usually in first 2wk PP) -Flu like symptoms, red, hot painful area on one breast -Upper, outer quadrant of breast is most common site -Pain meds, effective milk removal, antibiotic therapy -Cracking around nipple -Caused by any event that can cause milk stasis -Bottle feeding, insufficient drainage (not a good latch/suck), rapid weaning, oversupply of milk, poor fitting bra, blocked milk duct, missing feedings -Most common infecting organism is S. aureus

BUBBLE-EET: EMOTIONAL STATUS CONTINUED

-Interactions with family -Level of independence Is mom starting to take charge? Is she doing most of baby's care -Energy levels Did she have c-section/long labor that might decrease energy? -Eye contact with infant Direct eye contact with baby En-faced position -Posture and comfort level with infant -Sleep and rest patterns -Be alert for mood swings, irritability, or crying episodes

OVULATION AND THE RETURN OF MENSTRUATION

-Interplay of hormones: estrogen, progesterone, prolactin, and oxytocin -Estrogen decreases after birth, progesterone increases again after menstruation -Nonlactating women: return of menstruation @ end PP (6wk) -Lactating women: return dependent on freq/duration of feeds, anywhere from 2-18mo -Ovulation can still occur before menstruation despite breast feeding -NOT AN ACCURATE METHOD OF BIRTH CONTROL

MUSCULOSKELETAL

-Joints return to prepregnant state except for feet (can be ½ size larger) -Fatigue and activity intolerance may occur -NANDA Nursing dx: Distorted Body Image -Women feel better now that they are no longer pregnant, but they have the appearance of pregnancy - support! -Remind them it took 9 months to get there so it is going to take time to get back to normal -Good body mechanics and correct positioning are important during this time -Prevent low back pain and injury to joints -After birth, muscle tone is diminished, and the abdominal muscles are soft and flabby

ORTHOSTATIC HYPOTENSION

-Major concern! -Especially in 1st shower - can vasodilate and pass out! -Elevate HOB for a few minutes before ambulating -Have client sit on side of bed for a few moments first (dangle!) -Help client stand up and stay with her -Ambulate alongside client and provide support if needed -Frequently ask client how her head feels -Stay close by to assist if she feels lightheaded -*When laying supine, lochia pools. When she stands up, she can have a gush and the blood loss can make her dizzy

AFTER PAINS

-Part of involution -Contractions—occur to constrict blood vessels in uterine muscles -Oxytocin contributes to this!!! (natural!!) -Secreted from pituitary gland -Breastfeeding can contribute to oxytocin release!!! -Stimulates uterine contractions which in turn helps the uterus fold on itself -Mild analgesic may be administered due to pain of contractions - Tylenol, Motrin -Standing order: Pitocin directly after birth!!

NURSE'S ROLE

-Physical care -Emotional support Adjusting to the change of a newborn Often overwhelming, especially if it is first baby or there were complications during birth -Education Education is biggest role—especially if they're first time moms! -Cultural assessment Examples: Are they going to breastfeed? How involved is significant other? Will baby boy be circumcised? Sleeping arrangements

INTEGUMENT SYSTEM

-Pigmentation fades (linea nigra, chloasma) -Due to estrogen/progesterone levels going back to normal -Stretch marks fade to silvery lines -Typically on abdomen and breasts -Hair loss after pregnancy most common during first 3mo (drop in estrogen)—should return to normal within 4-6 months -Diaphoresis common for about a week postpartum

THROMBOEMBOLIC CONDITIONS: MANAGEMENT

-Prevent thrombotic conditions SCDs, walking, fluids, elevate legs, smoking session, heparin/aspirin, stop oral contraceptives -Promoting adequate circulation Ambulation, ted hose, SCD -Educating the client Anticoagulant therapy—watch for bleeding (nose bleeds, blood in emesis (coffee grounds), black/tarry stool, easily bruised)

UTERINE INVOLUTION

-Process of uterus returning to its normal size -Starts to close in/fold in on itself -Allows clamping down & constriction of blood vessels to stop bleeding -After birth, uterus weighs 1000g---in one week it's half its size and is back to normal after 6 weeks -Contraction of smooth uterine muscles start to help it involute on itself (clamp down) -R/t decrease in estrogen/progesterone -oxytocin - released by pituitary during breastfeeding -pitocin - we give in hospital

Traction

-Pulling of the umbilical cord causing uterine inversion (flip inside out) -prevents myometrium from contracting/retracting, and is associated with life-threatening hemorrhaging and profound hypotension -maternal symptoms are pain, profuse bleeding, and shock

BECOMING A MOTHER (BAM)

-RN has big role for the first 2 stages; assist the mom into becoming a mom 1. Commitment, attachment to unborn baby, preparation for delivery and motherhood during pregnancy (learn, classes, prenatal care) 2.Attachment to infant, learning to care for, and physical restoration 2-6 weeks post birth (postpartum) 3. Moving toward a new normal 4. Achievement of a maternal identity through redefining self to incorporate motherhood - around 4mo (teach ab self-care, baby care)

ACTIVITY, REST, EXERCISE

-Regular exercise - walk and increase length of walk -Kegels -pelvic floor exercises -Promote rest! More sleep disturbances can put them at risk for PP depression -Limit unnecessary visitors if possible -Figure out baby's sleep pattern - sleep when baby sleeps! -Share household tasks to conserve energy -Exercising too much too soon can cause women to bleed more -Eat balanced diet

IMMUNIZATIONS

-Rhogam may be needed—72 hours after birth if baby is positive and mom is negative -Rubella—cannot get pregnant right after (wait about 3 months, need good contraceptive) Nursing mothers can be vaccinated!!! -Varicella- same deal as rubella (both are live virus) -Tdap—will check titer levels first (protects against pertussis)—any caregiver around baby should have titers checked

NURSING ASSESSMENT

-Risk factors (what puts mom at risk for PPH?): multi gravida, long labor, stretched uterus, hydramnios, large baby -Uterine tone Boggy/firm, midline, position (U/U?) -Vaginal bleeding # pads saturated/hr, estimated blood loss at birth -Soft and boggy uterus indicates uterine atony -If trauma is suspected Uterus might feel firm with a steady stream or trickle of bright-red blood -Assess hematoma Uterus firm with bright red bleeding Observe for localized bluish bulging area under skin in perineal area (can hold 250mL)

Blood pressure

-Should return to pre-pregnancy level -Can be slightly lower the first two days PP -Preeclampsia - may take longer to return to normal -Decreased BP may suggest an infection or a uterine hemorrhage

PP PSYCHOSIS

-Significant increased risk for suicide and infanticide = -DO NOT LEAVE MOM WITH BABY! -Sx -Mood lability -Delusional beliefs -Hallucinations -Disorganized thinking -Sleep disturbances -Fatigue depression -Early sx resemble depression -Thoughts of hurting herself and infant -Greatest hazard is suicide Infanticide and child abuse -Need medicated -Occurs at 3 months PP

LOCHIA

-Sloughing off of endometrial tissue - due to low progesterone -Amt - scant, small, moderate, large -Should have fleshy smell -Foul odor indicates infection -Bright red - laceration (not sutured enough)

Pulse

-Slower HR🡪 May be bradycardic -It can run from 40-60 BPM -It will then return to baseline -You worry about tachycardia—this first sign of hemorrhage -Dehydration can occur

Attachment

-Strong affection -Between an infant and a significant other (mother, father, sibling, caretaker) -Reciprocated ex: baby smiles at mom -En face position (face to face)

SUBINVOLUTION

-Subinvolution = incomplete involution of uterus -Caused by: -Full bladder -Uterus up and deviated to the right -Retained placental fragments -Atony (stretching of uterus) -Multiple births, macrosomia, hydramnios

Bottle-feeding:

-Supportive bra -Suppression takes 5-7 days -Mild analgesics for discomfort -Shower run on back! -Avoid breast stim/ice!

ENGORGEMENT

-Swelling of the breast tissue due to an increase in blood flow & lymph supply as a precursor to lactation Occur from infrequent feeding or ineffective emptying of the breasts -Breasts will be hard and tender to touch Full, tender, very uncomfortable -Relieved by frequent emptying, warm showers, pump, manually express, cold compress b/t feeds Breasts need to be stimulated by a nursing infant, a breast pump, or manual expression of milk

Postpartum depression and psychosis

-Symptoms last longer and are more severe and require treatment -Poor bonding, alienation from loved ones, daily dysfunction and violent thoughts/actions -Feelings of restlessness, worthlessness, guilt, hopelessness, moody, sad, overwhelmed -2wk checkup - EPDS screening tool!

THROMBOEMBOLIC CONDITIONS: ASSESSMENT signs and symptoms PE

-Tachycardia -Low BP -SOB -JVD -Chest pain -Diaphoretic -Dyspnea -Tachypnea

REVA RUBIN'S 3 PHASES

-Taking-in phase (24-48h after birth): -Taking-hold phase -Letting-go phase

PP INFECTION MANAGEMENT

-Teach: Call if temp 100.4+ Call if chills Call if change odor/color lochia REEDA Wipe front/back Rest Peri care (change pads frequently, peri bottle) -Infection prevention Aseptic tech, handwash, peri care Screen visitors -Antibiotics Full course

VITALS

-Temp Slight fever 1st 24h (up to 100.4F) Due to trauma/dehydrated Return to norm in 24h 100.4+ = infection! -Pulse 60-80bpm @ rest tachy 100+ = rule out comps (hemm, infec) First thing to worry about!!! -Resp Return to norm 12-20 -BP Return to norm 140-90/85-60 -Pain 5th vital sign PQRST (precipitate, quality, radiates, severity, timing)

PP BLUES TEACHING

-Transient emotional disturbances -Anxious, irritable, insomnia, crying, loss of appetite, and sadness -Symptoms usually begin 2 to 4 days after childbirth and resolve by day 8-10 (worry if symp last 2wk) -Blues typically resolve with sleep! -Postpartum depression and psychosis are more serious and require professional referral

Metritis

-Uterine cavity is sterile - until ROM -Infection of endometrium, decidua, and adjacent myometrium (these are layers of uterus) -Abd pain -Elevated temp -Fatigue, lethargy, n/v -Anorexia -Causes: prolonged ROM, many vaginal exams, ascending infec

Tone

-uterine atony -commonly results from overdistention of uterus caused by multi. gestation, macrosomia, hydramnios, fetal abnormality, placental fragments, distended bladder -uterine atony leads to hemorrhage quickly which leads to hypovolemic shock

Trauma

-vaginal, cervical, or uterine injury cervical laceration often due to forceps -Macrosomia can tear uterus/cervix -Uterine rupture -Uterine inversion

DURING THE POSTPARTUM PERIOD, A NURSE SHOULD ASSESS FOR SIGNS OF NORMAL INVOLUTION. WHICH STATEMENT WOULD INDICATE THAT A CLIENT IS PROGRESSING NORMALLY? A. The uterus is descending at the rate of one fingerbreadth per day. B. Blood pressure drops as a result of the birth and changed circulatory load. C. Urine output remains about the same as in the client's prenatal period. D. Perineal pad usage remains at 10 to 15 per day.

A. The uterus is descending at the rate of one fingerbreadth per day. Rationale During the normal involutional process, the uterus will descend approximately one fingerbreadth per day. Blood pressure doesn't change during the postpartum period. Urine output typically increases after childbirth. Usually, the client will need six to seven perineal pads per day at this time.

A 2-DAY POSTPARTUM CLIENT TELLS THE NURSE THAT SHE IS EXPERIENCING ABDOMINAL CRAMPS WHENEVER SHE BREASTFEEDS HER BABY. WHICH OF THE FOLLOWING IS THE MOST APPROPRIATE RESPONSE FROM THE NURSE? A. "Progesterone levels increase after birth of the placenta, which triggers milk production and uterine contractions." B. "Oxytocin is released when the baby sucks, which causes the uterus to contract." C. "The baby is feeding too frequently causing the uterus to be hyper-stimulated." D. "The cramps will stop after your body has expelled all blood clots from the uterus."

B. "Oxytocin is released when the baby sucks, which causes the uterus to contract." Rationale Afterpains, which are intermittent cramping of the uterus, tend to be noticed by multiparas rather than primiparas. In this situation, the uterus must contract more forcefully to regain its prepregnancy size. These sensations are noticed most intensely while breastfeeding because the infant's sucking causes a release of oxytocin from the posterior pituitary, increasing the strength of the contraction

WHILE THE NURSE IS ASSESSING THE FUNDUS OF A MULTIPAROUS CLIENT WHO GAVE BIRTH 24 HOURS AGO, THE CLIENT ASKS, "WHAT CAN I DO TO GET RID OF THESE STRETCH MARKS?" WHICH RESPONSE WOULD BE MOST APPROPRIATE? A. "As long as you don not get pregnant again, the marks will disappear completely." B. "They usually fade to a silvery-white color over a period of time." C. "You will need to use a specially prescribed cream to help them disappear." D. "If you lose the weight you gained during pregnancy, the marks will fade to a pale pink."

B. "They usually fade to a silvery-white color over a period of time." Rationale: Stretch marks, or striae gravidarum, are caused by stretching of the tissues, particularly over the abdomen. After birth, the tissues atrophy, leaving silver scars. These skin pigmentations will not disappear completely. The striae gravidarum may reappear as pink streaks if the client becomes pregnant again. Special creams are not warranted because they are not helpful and may be expensive. Weight loss does not make the marks disappear. Striae gravidarum tend to run in families.

WHEN ASSESSING AN 18-YEAR-OLD PRIMIPARA WHO GAVE BIRTH TO A VIABLE NEONATE UNDER EPIDURAL ANESTHESIA 24 HOURS AGO, THE NURSE DETERMINES THAT THE FUNDUS IS FIRM BUT TO THE RIGHT OF MIDLINE. BASED ON THIS FINDING, THE NURSE SHOULD FURTHER ASSESSES FOR: A. uterine inversion. B. paralytic ileus. C. urinary retention. D. perineal hematoma.

C. urinary retention. Rationale: A full bladder is likely to push the uterus to the right of midline, so the nurse should further assess for symptoms of urinary retention. A full bladder can prevent the uterus from contracting properly (uterine atony), possibly leading to hemorrhage. When the bladder is empty, it normally is nonpalpable and lies about in the midline.

A NURSE IS CARING FOR A WOMAN WHO GAVE BIRTH TO HER BABY BOY 2 HOURS AGO. THE NURSE NOTES THE WOMAN'S PERINEAL PAD CONTAINS SOME SMALL CLOTS AND A MODERATE AMOUNT OF LOCHIA HAS ACCUMULATED UNDER HER BUTTOCKS. WHAT IS THE FIRST ACTION THE NURSE SHOULD TAKE AT THIS TIME? A. Request a prescription to administer oxytocin. B. Perform an in-and-out catheter immediately. C. Measure blood loss by measuring perineal pad. D. Check fundus for position and consistency.

D. Check fundus for position and consistency. Rationale While the greatest risk of postpartum hemorrhage is within the first hour following birth, a woman can develop an early postpartum hemorrhage anytime within the first 24 hours post-birth. As soon as the nurse notices an increased amount of lochia and clots, the fundus must be assessed for firmness and position. Normally, it should be firm, midline, and either just above or below the umbilicus

DURING A POSTPARTUM EXAMINATION, THE MOTHER OF A 2-WEEK-OLD INFANT TEARFULLY TELLS THE NURSE SHE FEELS VERY TIRED AND THINKS SHE IS NOT A GOOD MOTHER TO HER BABY. WHICH STATEMENT BY THE NURSE WOULD BE BEST? A. "The hormonal changes your body is experiencing are causing you to feel this way." B. "Most new mothers feel the same way that you do. I hear that a lot from others." C. "You need to have your husband and family help you so that you can get some rest." D. "I am concerned about what you are experiencing. Tell me more about what you are thinking and feeling."

d. "I am concerned about what you are experiencing. Tell me more about what you are thinking and feeling." Rationale The nurse should convey empathy and invite the client to share more about her thoughts and feelings so that the nurse can assess the mother for possible postpartum depression, which usually occurs between 2 weeks and 3 months after the baby's birth but also can occur later. Postpartum depression is a mood disorder with symptoms of tearfulness, mood swings, despondency, feelings of inadequacy, inability to cope with the baby, and guilt about performance as a mother. Postpartum depression commonly goes undetected because of poor recognition and lack of knowledge