OB Exam 5
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. What would you like to do?
If a pt is bleeding lots PP what do I check?
fundus and bladder....pee!!
How long is the PP period (Puerperium)
1st 6 weeks after delivery
returning of uterus to pre pregnancy size/condition
Describe the uterus immediately post delivery, then after
- immediately it is btwn pubic symphysis and umbilicus
- it goes above the umbilicus
How much does the fundus descend each day and when should it be no longer palpable?
What influences involution of the uterus?
- full bladder
- multigravida uterus
- breast feeding
How does the multigravida uterus effect involution?
it will be more painful cuz it is stretched so much
How much Pitocin to help with involution
Breastfeeding helps with involution cuz....
it secretes oxytocin which helps with contractions to shrink uterus
Describe lochia by day
first 3 days....rubra which is red...heavy when 1st get out of bed
days 3-11....serosa which is pink....will be home...made of leukocytes, blood and mucus
3 to 6 weeks....alba which is white/cream made of leukocytes
Teaching about lochia
it is abnormal to have large clots, foul odor and increase changing pads once hit alba stage.
if start to bleed again....rest, if it doesn't stop call doctor
Hormones that increase and decrease to cause milk production at 2-5 days after birth
- increased prolactin
- decreased progesterone, estrogen and placental lactogen
What helps with engorgement for breast feeding moms
How do you help non breast feeding moms with engorgement?
binding the breasts and put ice in the bra
Result of engorgement
slight increase in temperature....but if it is less than 100 it is ok
Blood loss for c section and vaginal deliveries
- c section=1000
up to these amounts
Why is cardiac output increased for 48 hrs after delivery?
cuz blood is returning from the uteroplacental unit back to the heart
extracellular fluid is moving in to vascular departments
What happens with plasma volume after delivery?
when will it be at a normal level?
it decreases due to diuresis and diaphoresis which rids the body of excess fluid
What happens with fibrinogen after delivery?
it is still increased so there is still an increased risk for thrombus formation
What happens with leukocytes after delivery?
they can increase to btwn 20,000-30,000 from pain, stress and inflammation
normal levels around 3-7 days
How long will it take for hormonally induced skin changes to revert back to pre-pregnancy states?
it takes a while for hormones to decrease...especially melanocytic stimulating hormone
What will happen to stretch marks pp
What happens with urinating and the pp patient?
temporary incontinence due to trauma and edema
**be with patient the first time they get up to urinate.....give them call light and tell them!!
What does diuresis occur after delivery
within 12 hrs
What can cause a pp patient to have a hemorrhage?
increased incidence of urinary retention....this displaces the uterus to the side so it cant contract...bleeding
What determines how a person does cardio wise with their delivery and pp?
When do cardiac events/myopathy occur after delivery?
within first few days
What hormone allows the ligaments and cartilage to return to pre prego position? How is this felt?
- Fatigue/joint aches
How long will it take the musculoskeletal system to get back to pre prego shape?
Which abdominal muscle has a really hard time getting back to pre prego site?
diastasis recti....longitudinal muscle that separates
What is common post partum?:
Post epidural feelings....
- lower extremity sensations
What is a sign that PIH is worsening
- blurred vision
- ABDOMINAL PAIN
What hormone initiates milk production within 2-5 days of delivery?
prolactin from the pituitary gland
What causes milk let down from the alveoli in to the lactiferous ducts?
oxytocin...from pituitary gland
If a person isn't breastfeeding how long will it take for prolactin to disappear?
Menstruation is hormonally controlled....how long till non nursing moms get it back?
- non at 2-3 months
- nursing it depends on the breastfeeding frequency....women who feed 6+ times/day will menstruate later than those who breast feed less often
How much is lost with the delivery of the fetus, palcenta, AF and blood?
During the first few weeks what causes weight loss and how much usually?
diuresis, diaphoresis and shrinking reproductive organs
Normal pre prego weight takes
PP assessment and nursing care for all births
- IV Fluid check
- Lower extremity
- Deep tendon reflexes
How often take VS after delivery?
- q 15min x 1hr
- q 30 min 2-4 hrs
Why is a new mom at risk right after birth for orthostatic hypotension?
there is a rapid decrease in intrabdominal pressure which leads to dilation of visceral blood vessels
Nanda for new mom
Risk for injury
If give methergen for pp contractions what do I watch for
Sign that the bladder is distended....
- fundus is displaced to the left or right
- suprapubic distention
What do I assess on the perineum after an episiotomy/laceration?
How does a mom care for her episiotomy/lacerations in perineum
1st 24 hrs ice....after that a warm bath to help with healing
How do you evaluate a hematoma in the perineum?
patient side lying, knees bent and look at from behind.....ask about pain level
Pain and the new mom....
never assume it is just in the abdomen....can be anywhere and we need to ask to describe
Hemorrhoids are a sign of
Why do we do a deep tendon reflex on pp mom? problem and what dx it?
- checking for PIH
- 3/4...hyperactive reflexes
Rubella and the nursing mom
If they need the vaccination they will still get it even though it will cross over to the breast milk
Additional focused assessment for a mom who had a c section
- abdominal incision
Complications after all deliveries
- localized area of redness or swelling
- pain in the breast not relieved by analgesics
- abdominal tenderness
- pelvic fullness/pressure
- persistent perineal pain
- frequency, urgency, burning with urination
- abnormal change in character of lochia
- localized tenderness, redness or warmth of the legs
Benefits of breast feeding for the infant
- no allergies
- easily digested by infant
- decreased constipation
- no overfeeding
- decreased gas
- decreased ear infection
Benfits of breast feeding for the mom
- no heating milk
- decrease cost
- causes uterus to contract
- mom can rest
- weight loss
- decrease stinky diapers to deal with
Bendfits of breast feeding for the dad
- no heating milk
- decreased cost
- decrease stinky diapers to deal with
State benefits of formula feeding
- anyone else can feed baby
- mom can eat anything
- no meds passed to baby that mom took
- measurement is for sure
- maternal medical condition
3 phases of breast milk
- increase protein
- fat soluble vitamins and minerals
- low in calories
- increase in IMMUNOGLOBULINS
- laxative effect 1st week
What do the immunoglobulins received in the 1st phase of breast milk do for the baby?
colostrum helps to establish the normal flora of the intestines
- comes in at 4-10 days
- increase in calories, lactose and fat
after two weeks of lactation this is present and provides sufficient nutrients
Bluish in color
How do you combo breast/formula feed?
Wait till the baby is 3-4 weeks old to introduce formula because breastfeeding is based on supply and demand
What decreases a womans risk of breast cancer?
less number of menstrual cycles
Breastfeeding decreases a mom's risk of developing which 2 types of cancers?
breast and ovarian
Breastfeeding and a mom's bones
makes them stronger in life
Formula fed babies are more at risk to be....
obese later in life
Nutrition for the nursing mom
- increase calories 500/day
- 2-3 litres of fluid/day
- avoid foods that make infant fussy
Comfort measures for engorgement
- wear fitted bra for support
- ice packs
- warm shower before breast feeding
- cabbage leafs
- LIPS FLANGED OUTWARD
- ALL OF NIPPLE IN AND @ LEAST 1IN OF AREAOLA IN THE MOUTH
- TONGUE OVER LOWER GUM AND SCOOPED
- CHIN AND NOSE TOUCHING MOMS BOOB
- HEAR AUDIBLE SWALLOWING
- OBSERVE JAW GLIDE AND EAR WIGGLE
- NO PAIN, DIMPLING OF CHEEKS, SOUND OF AIR ESCAPING
The golden hour promotes....
bonding and attachment
a UNIDIRECTIONAL attraction from PARENT to child
It encourages time together/touch...especially in first 2 hours when baby is alert
RECIPROCAL bond through interaction BETWEEN parent and infant through MUTUALLY satisfying experiences
When does attachment start?
during pregnancy and continues after birth
How does an infant reciprocate attachment?
- eye contact
- response to voice
- be consoled
first touch experiencing between mom and newborn when the mom explores the infant's body mainly with her fingertips
mom uses entire hand to touch infant
Verbal behaviors seen when bonding with baby
talks to infant
3 maternal role adjustments
- Taking in
- Taking Hold
- Letting GO
Describe taking in
- 1st day
- mom focuses on her own physical needs
- content letting others do things and make decisions
Describe taking hold
Mom is independent and is taking care of herself and baby...she is also ready to learn
When is a good time for patient education?
Taking Hold phase
Describe Letting Go
relinquish fantasy of infant and birth and realize old care free life is OVER
3 Placental abnormalities
Placenta accreta-superficial penetration of uterine muscle
Placenta increta-partial penetration
Placenta Percreta (perforated) complete penetration
What will be a sign that a pregnant person has placenta Percreta?
bleeding during pregnancy
What can Placenta Accreta, Increta and Perceta precipitate? Then....
- Uterine Inversion
What is Uterine Inversion? How does this happen?
- when the uterus turns inside out, either partially or completely
- happens cuz dr. pulled on cord before detachment, from fundal pressure during or after birth, abnormally adherent placenta
Result of Uterine Inversion
risk for Hemorrhage
Placenta accrete/increta/percreta and uterine inversion all put mom at risk for
When a patient is bleeding we want to know
Where blood is coming from....the episiotomy? Or hemorrhaging?
Sign that a patient has uterine atony
increased lochia rubra
when the uterus doesn't contract down or does it slower than expected...will have late PP hemorrhage
S/S of Uterine Atony
- soft/boggy or difficult to find fundus
- uterus gets firm with massage, but loses its firmness when massage is stopped
- fundus located above expected level/displaced
- excessive lochia/clots
- tachycardia/tachypnea/decreased BP
- Cool pale skin, hypovolemic shock
- Change in LOC
What is considered to be excessive lochia and clots?
>1 pad in 15 min
S/S of a hematoma....and can cause
- unrelieved deep perineal/rectal pain
- bulging mass or discoloration
- firm fundus
What do I do if a patient is hemoraghing?
- Fluid Bolus...may need 2nd line
- Supine position
- VS q 15min
- Foley to assess for bladder distention
- Meds to help contract uterus
- Bimanual compression of uterus
- Manual removal of placental parts
- Prepare OR for D&C
Meds given to help with contractions
- Pitocin 20u
- Methergine 0.2mg IM...can take orally at home
What lab do I need to monitor when a patient is hemoraghing?
Platelets....can go in to DIC
2 times patients are at risk for hemorrhage?
right away and 6 weeks pp
slower than expected return of uterus to pre-pregnancy size....problem after discharge home
S/S of subinvolution
- prolonged lochia discharge
- excessive uterine bleeding
- pelvic pain, backache, persistent malaise....less O2 to the brain=tired
- uterus feels larger/softer than expected for time
What causes subinvolution
- retained placental fragments
- pelvic infection
- uterine tumors
Therapeutic management for subinvolution
- **focus on patient ed since this happens after mom goes home....teach when to call Dr and go to ED
- Antimicrobial therapy
development of thrombus when a vein wall is inflamed...platelets & thrombin collect on vessel wall....can be seen in
legs or pelvis
S/S of thrombus
- no symptoms or
- pain in leg/pelvis/abdomen
- edema, redness
- cord like vein
- increased temp/chills/tachy
- decreased peripheral pulses
What can cause venous stasis which can cause a thrombus?
- compression of large vessels of pelvis and legs by growing uterus or
- prolonged time in stirrups
How do you treat a thrombus?
PREVENT ONE....limit time in stirrups! Only in stirrups when Dr. is there and ready to deliver
- bedrest with elevated leg
- apply moist heat
- Elastic hose
- don't massage
- know s/s of PE
S/S of Pulmonary Embolism
- sudden sharp chest pain
- SITTING IN TRI POD POSITION
- Decreased O2 sats
Management of PE
- Rapid Response
- Crash Cart
- IV Heparin
- Thrombolytic Drugs
- Elevate HOB....reduces dyspnea
- Pulse Ox
- Prepare for respiratory/cardiovascular support
Metritis and complication
infections of the uterus by staph, strep or e coli
causes sterility from inflammation of fallopian tubes
When will you see metritis? S/S?
- 2nd/3rd PP days
- 100.8 fever +
- abdominal pain/cramping
- uterine tenderness
- purulent/foul smelling lochia
What causes metritis
- *numerous vaginal exams
- delivery/c section
- ruptured membranes for too long causing over colonization of normal bacterial inhabitants
Therapeutic Management of Metritis
- Differentiate temp from dehydration vs. infection
- IV antibiotics...then oral
- oxytocics to promote drainage
- fowlers postion (drainage)
lactating breast infection
S/S of mastitis
- flu like symptoms
- temp >101
- *localized redness
What causes mastitis
- poor handwashing
- nipple injury
- skipped feedings/sudden cessation
- constricting bra
- decrease in rotation of positioning when feeding
- lowered maternal immune system
How do you prevent mastitis?
- wash hands
- feed correctly with different positions preventing engorgement
- feed every 2-3 hrs
How do you treat mastitis?
- continue with feeds
- apply moist heat before feeding
- ice between feedings
- empty breasts to prevent stasis of milk
- teach how to express milk or use a pump
- drink 3000 fluids each day
- admin antibiotics
usually within 1 week and is normal and to be expected
transient and due to temporary hormonal adjustment
How do you support a mom with post partum blues?
let her cry!!
happens 1 month to 1 yr and lasts at least 2+ weeks
S/S of Postpartum Depression
- loss of interest in daily life
- no emotion towards family
- no pleasure/love
- sees infant as demanding...can be true
- feelings of guilt/shame/unworthiness
- fatigue and cant concentrate
- appetite and sleep disturbances
- panic attacks
- obsessive thoughts
What puts a mom at risk for postpartum depression?
- hx of depression
- weak support system
- 1st time mom
- sleep deprivation
- poor diet
rare...happens 3 weeks pp
same s/s as PP depression but person will have delusions and won't know they have a problem.
poor judgment and infant is at risk...NEVER leave them alone with an infant
What makes you at risk for PP psychosis
bipolar or manic depressive usually without mania
3 ways to decrease you likelihood of post partum depression/psychosis
- eat well
- get a good nights sleep
- join a support group
Person with PP depression/blues/psychosis NANDA
risk for ineffective coping
What would you like to do?
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