OB Exam 4 CH 15-19 Postpartum/Newborn period & complications

taking-in phase

1-2 days after birth when client needs sleep, depends on others to meet needs, relives & talks about events of birth process

knee-chest position PP

AVOID until 3rd PP wk; causes vagina to open air can enter vagina, pass into cervix and enter open blood sinuses -> can lead to air embolus

BUBBLE-HE

Breasts Uterus Bladder Bowels Lochia Episiotomy (incision) Homan's sign (legs) Emotions/bonding

For the woman who is not breast-feeding her newborn, which measure would be most appropriate to relieve engorgement? A.Warm showers B.Nipple stimulation C.Ice to the breasts D. Manually expressing milk

C

You assess a postpartal woman's fundal height every 15 minutes during the first hour postpartum. At which of the following locations would you expect to assess the height of her fundus? A.Two fingerbreadths under the umbilicus B.One fingerbreadth under the umbilicus C.At the umbilicus D.Two fingerbreadths above the symphysis pubis

C

PP infection

CBC w diff, UA C&S, blood, cervical, uterine, wound cultures prevention is key ROM 24H+ placental fragments pp hemorrhage anemia prolonged labor internal FHR monitoring local infection before birth uterus was explored fever 100.4F or greater 24H after birth

A postpartal woman is having difficulty voiding following delivery. What should the nurse expect as the most reasonable cause for the difficulty voiding? A.The bladder fills slowly following childbirth. B.She is not trying hard enough. C.She must have a cervical tear, reducing bladder sensation. D.Perineal edema makes voiding difficult.

D

A postpartum woman is diagnosed as having endometritis. Which position would you expect to place her in based on this diagnosis? A.Flat in bed B.On her left side C.Trendelenburg D.Semi-Fowler's

D

sucking reflex

Reflex that causes a newborn to make sucking motions when a finger or nipple if placed in the mouth

peritonitis

infection of peritoneal cavity; extension of endometritis

PP discharge coitus

safe after 6wks & released by HCP use of contraceptice foam/lubricating jelly for comfort

development of parental love, positive family relationships

- perform needs assessment to identify parents' knowledge & skills - use good communication & listening skills to provide support - empower parents by assisting them in recognizing their own strengths - facilitate parents' actions to participate in decision making process - provide learning opportunities that move the parents from dependence to independence and self-reliance

letting-go phase

2-6wks after birth third phase of maternal adaptation; occurring later in postpartum (typically at home); occurs when woman reestablishes relationships with others

PP hemorrhage

24H period after birth >500mL BL following vaginal >1000mL BL following cesarean tachycardia, low BP, o2 sats <95% weigh pads most common cause is uterine atony -lacerations of genital tract, retained placental fragments, uterine inversion, coagulation disorder, hematomas mgmt: underlying cause (increase uterine tone, remove retained placental fragments, abx for infection, repair of lacerations) fundal massage is first step in controlling assist to bathroom, o2 4L/min, VS, fluids, s/s of shock, bimanual compression, blood replacement, hysterectomy if needed

postpartum psychosis

3wks PP; sleep disturbances, fatigue, depression, hypomania, thoughts of infanticide or suicide

Vitamin K is routinely administered to newborns because A.lack of vitamin K leads to faulty blood clotting. B.vitamin K is important for digestion of milk. C.vitamin K is important for lung maturity. D.lack of vitamin K is caused by immature liver action.

A

lab data 24H PP

H/H - 12-24H after birth hgb lower than 10g/100mL, iron may be supplemented

engorgement

Process of swelling of the breast tissue due to an increase in blood and lymph supply as a precursor to lactation - frequent emptying, warm showers and compresses before feeding, cold compresses btwn feedings if breast feeding - feeling of tension in breasts on 3-4 days from formation of milk IF NOT BF - tight supportive bra, ice, avoidance of breast stimulation

average newborn statistics

RR 30-60 P 120-160 T 97.7-99.3 pink body, blue extremities two arteries one vein wt 2.5-4.3kg length 45-54cm head 34-35cm chest 32-33cm

colostrum

a specialized form of milk that delivers essential nutrients and antibodies in a form that the newborn can digest; present immediately after birth

relief of discomfort

afterpains - cramping usually lasts 3 days muscle aches perineal care - kegel's cold/hot therapy - apply cold pack to perineum during 1st 24H; warm sitz bath sitz bath - use 3-4x a day for max of 20 minutes each

bowel BUBBLE-HE

assess bowel sounds prevent constipation - administer stool softener (encourage early ambulation & good diet w ruffage/adequate fluid intake)

what should you do if the fundus is deviated?

assist pt to empty bladder

PP discharge work

avoid heavy work (lifting/straining) for 3wks do not return to outside job for 3-6wks

PP discharge contraception

begin with initiation of coitus IUD - can be fitted immediately after birth or first PP appt oral - begin 2-3 wks after diaphragm - refitted at 6wk chekcup OTC spermicidal jelly/condoms can be used

cervix PP

begins closure; appearing as a jagged slit-like opening after dilation and delivery of a child

neonatal period

birth to 28 days

lacerations

blood is bright red w/o clots and the uterus remains firmly contracted cervical - usually an arterial bleed, immediately after delivery vaginal - hard to repair, vagina may need to be packed perineal lacerations

emotions BUBBLE-HE

bonding/response

GI system PP

bowel tone & peristalsis - bowel sounds are active but bowels may be slow due to SE of relaxin during labor hunger/thirst - digestion/absorption begin to be active again soon after vaginal births hemorrhoids - distended rectal veins; have been pushed out of rectum during labor (often present)

When assessing the stools of a 1-week-old newborn who is being breast-fed, which would the nurse expect to find? a. Greenish-black tarry stool b. Seedy greenish-brown stool c. Yellow-gold loose stool d. Yellow-green soft formed stool

c

PP discharge hygiene

can take tub baths/showers apply cream/ointments ordered for perineal area, clean from front to back stitches will be absorbed in 10 days do not use douches

mother-baby care

care of postpartum mother and newborn by same nurse; centers on tx of mother and baby as one unit

disappointment

common in baby if they don't look as expected

evaporation

conversion of liquid to vapor (dry baby off)

rooming in

couplet care; baby stays in room with mother instead of central nursery

A postpartal woman tells you that her room must be too warm because she has been perspiring excessively since delivery. Which of the following is your best response? a. A."You should ask for a cooler room." b. B."Breastfeeding will decrease the problem." c. C."I'll take your temperature before you feed your baby." d. D."You should maintain a good fluid intake."

d

opioid analgesics PP

darvocet (propoxyphene/acetaminophen) 1tab oral Q4H PRN for pain percocet (oxycodone/acetaminophen) 1-2tab Q4-6H PRN for pain not contraindicated for breastfeeding tx of moderate-severe pain

stool softener PP

docusate 50mg-500mg oral bisacodyl 10mg-30mg oral until normal bowel movements not contraindicated for breastfeeding tx of constipation

femoral thrombophlebitis

elevated temp, chills, pain and redness in leg + homan's sign NSAIDs, bed rest, anti-embolism stockings, anticoagulant therapy (heparin) bf/(warfarin) not bf management: bed rest w affected leg elevated, admin of anticoagulants, application of moist heat DO NOT massage skin over clot

bladder BUBBLE-HE

encourage woman to walk to bathroom to prevent bladder distention if woman has not voided 4-8hrs PP, bladder is distended always measure first void after birth (less than 100ml or more than 150ml retained in bladder to determine if cath is needed)

the hormonal system PP

estrogen/progesterone return to pre-pregnancy levels after 1wk placental hormones decrease prolactin levels increase

vagina PP

eventual thickening and return of rugae after vaginal birth

diuresis PP

excessive sweating; body rids itself of excess fluid and noticeable in woman soon after birth (btwn 2-5PP days)

T/F: After birth, the cervix returns to its prepregnant shape

false

engrossment

fathers observing newborn; absorption, preoccupation, and interest in newborn gazing at infant for prolonged period of time

cardiovascular system changes at birth

fetal to newborn circulation placental to pulmonary gas exchange increased release of catecholamines critical for changes involved in transition to extrauterine life changes in fetal structures: foramen ovale, ductus arteriosus, ductus venosus, umbilical arteries and vein close

convection

flow of heat from newborns body surface to cooler surrounding air (drafts from windows/AC)

wt loss PP

fluid loss - 5lbs birth loss - 12lbs lochia flow - 2-3lbs total - 19lbs

physical assessment 24H PP

general appearance hair - brittle, firm face - edema, puffy eyelids? eyes - conjunctiva for color (determines anemia) clear/blood shot?

assessment 24H PP

health hx - aspects of woman's pg, labor, birth, complications?, L&D? family profile - support persons pg hx - GTPAL, planned/unplanned? infant data - sex, wt, difficulty? pp course - woman's general health

step in place reflex

holding the newborn upright with feet touching a flat surface; newborn responds with stepping movements

NSAIDs PP

ibuprofen 400mg oral Q4-6H PRN for pain not contraindicated for breastfeeding tx of mild-moderate pain

newborn respiratory assessment

if alveoli do not open well, cardiac system becomes compromised bc closure of foramen ovale and ductus arteriosus depends on free blood flow through the pulmonary artery and good oxygenation of blood

palmar grasp reflex

in response to stroking a baby's palm, the baby's hand will grasp

episiotmoy BUBBLE-HE

incision; use REEDA episiotomy 1-2in long perineal assessment (sim's position facing door w back towards nurse) excessive swelling, discoloration, incisional separation, discharge other than lochia should be reported check for presence of hematomas

subinvolution

incomplete return of uterus to pre-pg size/shape

uterus BUBBLE-HE

increases risk of hemorrhage; assessment is important assess consistency (firm, soft, boggy), location (midline), and height height of umbilicus or even slightly above it

mastitis

infection of breast care of nipples - position infant correctly - releasing baby's grasp on nipple - washing hands btwn handling pads - exposing air to nipples - vitamin E unilateral; painful, swollen, reddened flu-like s/s fever tx: abx, continue bf

endometritis

infection of endometrium, decidua, and myometrium tx: cleocin, fluids, fowler's or walking

thromboplebitis

inflammation of lining of blood vessels w formation of clots; can be extension of endometrial infection due to venous stasis, inactivity, injury to inner most blood vessel, obesity, hypercoagulation/fibrogen elevation, cigarette smoking SVD or DVT

return of menstrual flow

interplay of hormones - estrogen, progesterone, prolactin, oxytocin non-lactating women - return of menstruation 6-10wks after birth lactating women - dependent of breast feeding frequency and duration; returns in 3-4 mo. or entire bf time (does not mean absence of ovulation) lactation is not a reliable method of contraception

PP uterine changes

involution - fundus is usually midline of abdomen or slightly to the right hour 1 PP is crucial, **if uterus relaxes, she will lose blood rapidly bc no permanent thrombi have formed** afterpains - intermittent cramping of uterus after birth

perineum PP

labia majora & minora typically remain atrophied and softened after birth

topical anesthetic PP

lidocaine spray; to perineal area after sitz bath/perineal care not contraindicated for breastfeeding tx to relieve skin pain/itching

PP discharge exercise

limit stairs one flight/day for first wk if lochia is normal, increase activity continue with muscle strengthening exercises

en face position

looking directly at newborn with direct eye contact; sign woman is beginning bonding

DIC

low hct, hcg, platlets, fibrinogen elevated fibrin/degradation products

newborn GI assessment

meconium usually passed within 24H breast fed babies - light yellow stools formula babies - bright yellow stools

postpartal depression

more serious level of sadness after birth 2wks PP may have suicidal thoughts; must have prompt referral and evaluation persistent, pervasive fatigue

abandonment

most women feel sense of abandonment as focus shifts from them to baby

neuromuscular function in the newborn

move extremities, attempt to control head movement, strong cry, and demonstrate reflexes *absence of response to manipulation is never normal and suggests narcosis, shock, or cerebral injury*

postpartal blues

normal; result of hormonal changes after delivery woman experiences feelings of sadness, mood swings, tearfulness that do NOT interfere with ability to care for infant 1st wk PP

follow up for PP care

notify HCP if increase in lochial discharge or lochia rubra 4-6wks for examination (involution is complete, HPV immunization, reproductive life planning)

PP discharge rest

one rest period each day/good night's sleep rest during day when baby is sleeping explore sitter options for relief

uterotonic medications

oxytocin hemabate (SE diarrhea) F2 methergine (SE HTN)

integumentary PP

pigmentation - linea nigra & chloasma can become barely detectable by 6wks stretch marks - appear reddened and may become more prominent than during pg (usually fade in 3-6mo)

breasts BUBBLE-HE

prevent/alleviate engorgement breast hygiene (wash w warm water, avoid soap bc of drying effect & breast creams)

uterine inversion

prolapse of fundus through cervix

cystocele

protrusion of the bladder into vaginal wall

rectocele

protrusion of the rectum into vaginal wall

postpartal period

puerperium; 6wk period after childbirth - "4th trimester" - marks child's introduction to the family - critical transition period *changes in all aspects of mother's life that occur during first year following birth*

PP PIH

s/s same as antepartum bed rest, quiet environment, monitor VS

pulmonary embolism

s/s: tachypnea, sharp pain in chest, tachycardia, orthopnea, cyanosis tx: oxygen, CPR, transferred to ICU

taking-hold phase

second and/or third day after birth second phase of maternal adaptation; characterized by dependent & independent maternal behavior focus shifts towards baby

lactation

secretion of milk by breasts result of interaction of progesterone, estrogen, prolactin & oxytocin typically appears 3days PP

UTI and breastfeeding

sulfa drugs prescribed

Homan's BUBBLE-HE

support thigh and foot, bend leg then abruptly dorsiflex ankle pain, resist dorsiflexion, involuntary knee flexion = positive

VS changes PP

temp - slight increase in 24hrs (100.4 after 24hrs = febrile) pulse - slightly lower (rapid, thready could indicate hemorrhage) BP - decrease could indicate bleeding; oxytocin can elevate BP (if over 140/90 withhold drug & notify HCP) always assess for OH (sit & dangle)

factors predisposing to heat loss

thin skin - blood vessels close to surface lack of shivering ability - limited stores of metabolic substrates (glucose, glycogen, fat) limited use of voluntary muscle activity large body surface area relative to body wt lack of subq fat; little ability to conserve heat by changing posture no ability to adjust clothing/blankets cannot communicate

radiation

transfer of body heat from solid object not in contact w baby (cold window/AC close to baby)

conduction

transfer of body heat to a cooler solid object in contact w baby (cover surface w warm blanket(=)

tonic neck reflex

turning the head to one side, extending the arm and leg on that side, and flexing the limbs on the opposite side (fencing position)

cardiovascular system PP

usual EBL 300-500mL for vaginal, 500-1000mL for cesarean blood volume returns to normal level by 1-2wks hematocrit - 4pt decrease in hct, 1g decrease in hgb within each 250mL of BL - excess fluid is excreted, hct rises (hemoconcentration) coagulation - high level of fibrinogen during first PP wks; protective measures against hemorrhage (high level increases thrombus formation & risk in PP period)

lochia

uterine flow consisting of blood, fragments of decidua, WBCs, mucus and some bacteria rubra - red; blood fragments of decidua and mucus (lasts PP day 1-3) serosa - pink; blood, mucus, and invading leukocytes (lasts PP day 3-10) alba - white/yellow; largely mucus, leukocyte count high (lasts PP day 10-14 up to 6wks)

blood coagulation

vitamin K necessary for formation of factor II, VII, IX newborn's intestines are sterile at birth takes about 24H for intestinal flora to accumulate and for vitamin K to be synthesized

urinary system PP

voiding sensation affected by - perineal lacerations (burning) - generalized swelling/bruising of perineum & tissues surrounding urinary meatus - hematomas - decreased bladder tone from regional anesthesia - diminished sensation of bladder pressure due to swellind/edema, poor bladder tone, and numbing effects of regional anesthesia used during labor

blood values at birth

volume varies depending on age; 80-90mL/kg of body wt hgb 13-21g/Hct 42-62% bilirubin 3mg/dL 1-2days: 3.4-11.5mg/dL 3-5days: 1.5-12.0mg/dL WBC 9000-30000

rooting reflex

when touched on the cheek, to turn toward the touch, open the mouth, and search for the nipple (disappears at wk 6)

hemorrhoid care PP

witch hazel (tucks) apply to perineal area after sitz bath/perineal care not contraindicated for breastfeeding tx of itchin, burning, irritation on skin from hemorrhoids