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1) Know the difference between estrogen, progesterone, & prolactin; which one increases/decreases after birth& beyond
a) Higher estrogen & progesterone stimulate growth of uterus during pregnancy, increasing total number of muscle cells & enlargement of existing cells.
b) Reduced level of E&P (post delivery) causes autolysis of extra cells & tissue of the uterus, promoting reduction in size.
- c) E&P levels drop dramatically once placenta is delivered.
- => Drop in estrogen = breast engorgement & diuresis of accumulated ECF from pregnancy.
- => Decreased estrogen = decreased vaginal lubrication, resulting in dryness (coital discomfort)
d) Non-lactating women's estrogen levels rebound more quickly than women who breastfeed.
- e) Prolactin levels rise throughout pregnancy and increase with each breastfeeding (or nipple stimulation).
- Prolactin levels are directly linked to frequency of breastfeeding/nipple stimulation & the duration of each.
- The more frequent baby is put to the breast and the longer he/she is allowed to remain, the higher the levelof serum prolactin—supply & demand.
f) Prolactin, in sufficient levels, suppresses ovulation & menstruation
2) Postpartum fluid loss (mom diaphoresing post birth)
a) Diuresis/diaphoresis occurs within 12* post-delivery
b) Occurs more often at night for first 2-3 days post-delivery
c) Caused by decreases in estrogen levels.
d) Results in reduced venous pressure in lower extremities, excretion of excess fluids and blood volume.
e) Mom will urinate often, though losses are also seen through increased perspiration.
3) Resumption of normal menstrual cycle; when will it start? Differences between breastfeeding/bottlefeeding; characteristics: heavy/light
a) Non-breastfeeding: 1-2 months post birth. Ovulation can occur as early as 27 days post-delivery in nonlactatingwomen; the average is 10 weeks. 70% resume menstruation by 12th week postpartum.
b) Breastfeeding: will not resume for duration of lactaction period (woman will still ovulate, must use birthcontrol to prevent pregnancy). Average ovulation occurs is 6 months. Resumption of menstruation isdependent upon breastfeeding pattern—dedicated & frequent breastfeeding delays menstruation;supplementing breastfeeding with bottle or solid foods promotes resumption of it. 50-75% of women whobreastfeed resume menstruation by the 36th week.
c) Menstrual flow will be heavier than normal for the first few cycles (about 3-4), regardless of breastfeedingstatus, until hormonal levels stabilize; after this period, flow returns to pre-pregnancy pattern.
Trimester periods: know all but specific to 4th (puerperium); see previous study guides for trimester period refresher.
Puerperium & Abnormalities
The time from delivery of the placenta through the 6th week post-delivery. At this point, thebody reverts to non-pregnant state. Includes:
- i) Involution of uterus; size of uterus is usually larger than pre-pregnant state;
- (1) Contractions to reduce uterus
- (2) Afterpains – more pronounced contractions
ii) Lochia – see below
iii) Cervix – closes, becomes firm, regains shape
iv) Vagina & perineum – returns to prepregnant size but not shape. Rugae is often permanently flattened.
v) Pelvic muscles – weakened by childbirth & may take up to 6 months to repair. Kegel exercises arerecommended to strengthen pelvic floor & aid in healing.
vi) Abdomen – still appears pregnant for first couple of weeks post-delivery. Takes 6+ weeks to return tonon-pregnant state.
- ABNORMALITIES:i) Hemorrhage – see below mentioned section
ii) Infection – see below mentioned section
iii) Septic pelvic thrombophlebitis – venous inflammation & thrombus formation with fever & unresponsive to antibiotics treatment. Infiltration of anaerobic bacteria that spreads systemically to other regions ofbody. Symptoms: fever > 38*; resting tachycardia; tachypnea & stridor (if pulmonary involvement;tender, palpable, rope-like mass in ovarian region. Treated w/ anticoagulants & antibiotics.
iv) Endocrine disorders – postpartum thyroid dysfunction; postpartum thyroiditis, resulting in hypothyroidism. Symptoms are same as hypothyroidism.
v) Psychiatric disorders – see Baby Blues section
5) When is the uterus no longer palpable (what week postpartum)
a) by the 10th day, uterus is no longer palpable
Breast engorgement .
decrease in estrogen/progesterone levels after delivery stimulates increase in prolactin, promotingbreast milk production. Engorgement occurs by day 4-5.
- b) Alleviation:
- i) Breastfeeding:
- (1) Support bra (no underwire) at all times, even during sleep
- (2) Ice packs between feedings
- (3) Warm shower or soak breasts in warm water
- (4) Analgesics if comfort measures fail
- ii) Bottle-feeding:(1) Avoid nipple stimulation—signals milk demand to body (induces prolactin)
- (2) Use breast binder or snug fitting bra
- (3) Ice packs to alleviate discomfort
- (4) Mild analgesics
- (5) Engorgement resolves in 24-36 hours after onset
Mastitis: How to minimize/alleviate:
i) Inflammation of parenchymatous (connective) tissue of the mammary glands resultant from infection
ii) Occurs in 1% of postpartum patients; usually primapara's who are breastfeeding; usually 2-3 weeksafter delivery, though it can occur anytime.
iv) Preventable with
- iii) Predisposing factors:
- (1) Fissure, crack, abrasion of nipple (from poor latch or overuse); pathogen (S. aureus) enters throughbreak in skin of nipple & travels to milk ducts. Milk provides an excellent growth medium.
- (2) Blocked milk ducts (from use of constrictive bra, underwire in bra, prolonged feeding intervals—waiting too long to feed baby)
- (3) Incomplete let-down reflex
good breast hygiene & hand washing
- v) Symptoms:
- (1) Warm, red, tender, & swollen area on the breast; typically only one breast is affected.
- (2) Elevated temp: >101* F
- (3) Flu-like symptoms: chills, malaise, headache
- vi) Interventions:
- (1) Wash hands before and after breastfeeding.
- (2) Apply warm compresses/take warm shower to facilitate milk flow prn.
- (3) Ensure proper positioning/latching on of baby on breast.
- (4) Empty breasts as much as possible when feeding. Alternate feeding positions/rotate pressure areas.
- (5) Offer affected breast first to promote complete emptying of breast & clearance of plugged duct
- (6) Release baby’s grasp on breast before removing baby from breast.
- (7) Expose nipples to air for a portion of the day (current data shows this isn't helpful).
- (8) Keep hydrated, eat balanced diet, and well-rested to enhance breastfeeding.
- (9) Check breasts for cracks or fissures—can lead to mastitis
- vii) Treatment:
- (1) Analgesic & antibiotics exactly as prescribed
- (2) Apply local heat
Involution of uterus after birth & 10 days later (in relation to umbilicus)
a) Involution = rapid decrease in size of uterus
b) breast fed moms experience more rapid involution
- c) uterus should be at midline
- i) at end of 3rd stage: fundus is usually midway betweenumbilicus & symphysis (2cm below umbilicus)
- ii) rises to 1cm above or at umbilicus 12* after birth
- iii) decreases in finger breadths/day (1-2cm/day)
- iv) by 6th day, fundus is ½ way between umbilicus & symphysis.
- v) by the 10th day, uterus is no longer palpable
- d) Fundal height is assessed on an empty bladder; if fundus is notat midline, suspect full bladder & have patient void.
- ***distended bladder impedes downward descent of uterus,pushing it up & to the side.
e) May need to augment with oxytocin, ergovine, methergine
f) Fundal assessment includes: Location, height (cm/fingerbreadths), & firmness.
- g) If fundus feels boggy, massage gently to stimulate contractions; increase pressure used for massage if uterus fails to respond.
- i) Caution: excessive massage can stimulate relaxation, producing uterine atony or inversion
Describe afterbirth pains and who is more likely to get them
a) afterbirth pains are a result of uterine contraction
b) more common in multiparas, breastfeeding moms, clients who receive oxytocin, and multi-fetus gestation(twins, etc)
c) ***multipara is more prone
Lochia & hemorrage
Know various types of lochia
vaginal discharge for the first 3 days after delivery; it has a fleshy odor and is bloody with small clots
vaginal discharge during during days 4 to 10; it’s pinkish or brown with a serosanguineousconsistency
yellow to white discharge that usually begins about 10 days after delivery; it may last from 2 to 6weeks
- d) Abnormalities:
- i) Foul odor indicates possible infection
- ii) Bright red blood indicates bleeding or hemorrhage; due to cervical/vaginal laceration.
- iii) Sudden change in color—bright red after being pink—indicates new bleeding, possibly from retainedfragments.
- iv) Lochia that saturates peripad in 45 minutes
- v) Blood pooling under buttocks
- vi) Large or numerous clots interfere with involutionvii) Absence of lochia – may indicate infection
- e) Assessing amount of lochia:
- i) Scant: less than 2.5 cm on pad in 1 hr
- ii) Light: less than 10 cm on pad in 1 hr
- iii) Moderate: less than 15 cm on pad in 1 hr
- iv) Heavy: saturated pad in 2 hrs
- v) Excessive: menstrual pad saturated in 15 min
- vi) Breastfeeding, exertion increase lochia flow
- vii) Color can range from red to pinkish-brown, tocreamy white or colorless.
f) To determine most accurately the amount of lochialflow, weight the perineal pad before and after use andidentify the amount of time between pad changes
How to estimate blood loss? What is normal for vaginal? What is normal for c-sect?
b) To determine:
- a) Average blood loss during childbirth:
- i) Vaginal = 500mL
- ii) C-setion = 1000mL
- iii) Hemorrhage is classified when there is a 10% difference in hematocrit levels from admission to postdelivery
- iv) Hemorrhage is characterized by complete saturation of peripad in 15 minutes or less &/or pooling of blood under buttocks (on chux pad).
- (1) Requires assessment & notification of MD
weigh peripad before/after, subtract
Postpartum hemorrhage –What type of woman has increased risk for postpartum hemorrhage? (Parity? Csect?Multi-gest? Preeclamptic?)
a) Greatest risk is from uterine atony. Multi-gestational (multi-fetus) or any condition that overextends uterusis a greatest risk for hemorrhage over other choices.
(b) uterine rupture, inversion
(c) placenta accreta
- Early Postpartum hemorrhage: occurs within 24* post-delivery
- (1) Causes:
- (a) Uterine atony—most common, 2nd to laceration. Failure of arteries & veins to close coupledwith increased blood flow to area (pregnant uterus)
- (i) Predisposition:1. Overdistention of uterus (multi-gest, polyhydramnios, large neonate)
- 2. grand multiparity
- 3. Dystocia—prolonged labor
- 4. Oxytocin administration5. Use of terbutaline or MgSO4
(cervix, perineum, labia); coagulapathy; vaginal laceration—most common, 2nd to uterine atony
caused by obstetrical intervention/augmentation of delivery (use of forceps, vacuumextractor), precipitous delivery, macrosomnia, & episiotomy.
(e) retained placenta;
incomplete placental separation
(f) DIC (disseminated intravascular coagulation)
—clotting factors & platelets that coagulate bloodwithin uterine blood vessels (though not limited to this area) at placental attachment site, preventing proper involution of uterus & causing hemorrhage. More common in those with a history of abrutio placentae, missed abortion or intrauterine fetal death.
- ii) Late postpartum hemorrhage: occurs 1-2 weeks post-delivery, as late as 6 weeks post –delivery; definedas a loss of >500ml within postpartum period
- (1) Causes:
- (a) Retained products (placenta)
- (b) Infection
- (c) Subinvolution of placental site
- (d) coagulopathy
- c) Other predispositions:
- i) Previous hx of postpartum hemorrhage
- ii) Placenta previa
- iii) Abruptio placentae
- iv) Multiparity
d) Estimate blood loss by pad count & evaluating pooled blood underneath perineum.
S/S of hypovolemic shock:
i) Peripad soaked in 15 min or less (may/not accompany changes in VS)
ii) Patient reports feeling light-headed, seeing stars, feeling ill
iii) Affect: anxious & irritated
iv) Pallor—ashen or gray
v) Cold, clammy skin
vi) Rapid, shallow respirations; air hunger
vii) Drop in urine output (<25ml/hr)
viii) Rapid, thready peripheral pulses; increased rate
ix) Decreased B/P
x) MAP (mean arterial pressure) <60mmHg
What is the 1st and most important intervention for profuse bleeding postpartum?
a) First & most important: determine cause of bleeding, call MD, control bleeding & minimize shock
- b) Objective in preventing hemorrhage: maintain good uterine tone & preventing bladder distension
- i) Call for backup
- ii) Determine cause of bleeding—turn patient on side to inspect area under buttocks & assess bloodpooling.
- iii) Treat for atonic uterus, if suspect
- iv) Elevate legs 30*; tilt woman on right side or elevate right hip.
- v) Monitor VS Q 5-15 min (increase HR = early sign; decrease B/P = late sign)
- (1) Assess skin color & temp note any changes.
- (2) Cold, clammy skin indicates progressive shock
- (3) Watch for petechiae, bleeding, bruising, or oozingvi) Monitor hgb, hct; I/O
vii) Rapid infusion of NS 0.9% or LR using large bore (14G – 18G) catheter to stabilize blood volume & prep for blood infusion. Large bore can also assist in the placement of PICC line
viii) Infusion of plasma expanders: albumin to maintain blood volume
ix) Administration of whole blood
- c) For uterine atony:
- i) Massage fundus to treat atony (do not leave patient); bi-manual massage may be necessary
- (1) Uterus may quickly relax when massage is discontinued, causing increased risk for negative outcomeof hemorrhage.
- ii) Administer oxytocin if uterus is unresponsive;(1) Be sure to frequently assess fundus, atony can reoccur.
- iii) IM administration of prostaglandins can promote strong uterine contractions (1) Tachycardia, hypertension, nausea, & diarrhea are side effects of prostaglandinsiv) Hysterectomy if bleeding is not controlled.
d) Lacerations, if the cause, are sutured
e) Retained placenta is removed by D&C (dilation & curettage)
f) DIC treated accordingly
Distended bladder: immediately after birth; post 2* after birth
a) Patient should void within first 6-8 hours post delivery;
b) Assess for distended bladder in first few hours post delivery—uterus skewed to midline
Dangerous vital signs postpartum (low BP, high HR)
- a) Normal vitals variations:
- i) Temp: may increase to 100.4 due to (d/t) dehydrating effects of labor.
- (1) temp > 100.4 = infection & must be reported
- ii) Pulse: may decrease 50 bpm (normal puerperal bradycardia) in the first 6-10 days postpartum becauseof reduction of vascular beds & decrease in cardiac strain/stroke volume
- (1) pulse > 100bpm = possible hemorrhage/significant blood loss
- (2) Report rapid, weak/thread pulse.
- iii) B/P: should return to pre-pregnancy level within 24 hours
- (1) decreases = hypovolemia (blood/fluid loss); check O-B/P
- (2) increases (>140/90) may suggest postpartum hypertension
- iv) Respirations: should be norm
- (1) Increase = possible pulmonary embolism, uterine atony, hemorrhage
Complications with uterine atony and uterine inversion:
17) Signs/symptoms/interventions of postpartum (puerperal) infection: fever, increased heart rate
- a) Puerperal infection characteristics (infection of uterus & higher structures—fallopian tubes, ovaries, etc)
- i) Temp > 100.4*F (38*C) within first 10 days post delivery—can happen post miscarriage.
- ii) Fatal if left untreated; can result in endometritis, parametritis, pelvic/femoral thrombophlebitis, orperitonitis. Can remain local or go septic.
- iii) Chills, backache, malaise, restlessness, & anxiety; lethargy
- iv) Foul smelling lochia
- v) Abdominal pain
- vi) Subinvolution of uterus (uterus fails to involute)
- b) Cause
- i) Introduction of microbes into sterile pelvic cavity/organs
- (1) Failure of aseptic technique during childbirth, surgical procedures, use of delivery assistive devices(forceps/vacuum), internal fetal monitors, c-sec
- (2) Prolonged PROM (over 24*)
- (3) Prolonged labor (>24*)
- (4) Retained tissues
- (5) Reduced immune system resulting from hemorrhage, anemia, malnutrition
- (6) Colonized bacteria present in vagina prior to labor/delivery
i) Localized perineal infection:
- ii) Infection organisms include:
- (1) Infections occurring within 1-2 days of delivery are usually caused by Group A streptococci
- (2) Infections occurring by days 3-4 post-delivery are usually enteric: E. coli, Pseudomonas, Klebsiella, P.miramirabilis
- (3) Infection developing more than 7 days is most frequently Chlamydia trachomatitis
- (4) Infection following C-sect is usually gram negative bacilli—B. fragilis
pain, ^ temp, localized edema & redness, firmness, tenderness at woundsite; heat sensation; burning on urination; discharge from wound.
heavy, foul-smelling lochia; tender, enlarged uterus; backache; severe uterine contractionthat persist long after childbirth;
iii) Parametritis (pelvic cellulitis):
vaginal tenderness; abdominal pain & tenderness; pain becomes moreintense as infection worsens.
iv) Septic pelvic/femoral thrombophlebitis:
severe chills & dramatic body temp swings; lowerabdominal/flank pain; possible palpable, tender mass over affected area that develops during 2ndpostpartum week.
elevated body temp; tachycardia > 140bpm; weak pulse, hiccups, nausea, vomiting,diarrhea; constant/excruciating abdominal pain; rigid abdomen w/ guardingPsychosocial
Difference between postpartum blues and depression—know warning signs (see table in text book)
a) Risks for postpartum depression
b) Interventions for postpartum depression
- a) Risks for postpartum depression
- Prenatal depression
- Discord in marital relationship
- Low self-esteem
- Hx of depression
- Stress of child care
- Difficult infant temperament
- Prenatal anxiety
- Postpartum blues
- Life stress Single status
- Lack of social support
- Low socioeconomic status
- Unplanned/unwanted pregnancy
- b) Interventions for postpartum depression
- i) Acknowledge client's feelings; demonstrate caring
- ii) Determine support systems (family, church, friends)
- iii) Encourage verbalization of feelings
Talking to Bereaved:
- Talking to the bereaved
- Phrases to say: "I'm sad for you" "How are you doing with all of this?" "This must be hard for you" "What can I do for you?" "I'm sorry" "I'm here and I want to listen"
- What to avoid saying:
- "God had a purpose for him/her" "Be thankful you have another child" "The living must go on" "I know how you feel" (even if you'veexperienced a similar loss, you DON'T knowhow they feel) "It's God's will" "You have to keep on going for her/his sake" "You're young: you can have others" "We'll see you back here next year, and you'llbe happier" "Now you have an angel in heaven" "This happened for the best" "Better for this to happen now, before youknow the baby" "There was something wrong with the babyanyway"
What is the normal grieving process for a grieving woman who just lost their baby (see lecture slides)? Whatis a normal response from a nurse?
- i) Important to establish/maintain therapeuticrelationship; active listening & giving space for grieving.
- (1) Intently listen to their story of loss
- (2) Permit family's use of silence (gives them a chanceto organize thoughts & feelings
- (3) DO NOT give advice OR use clichés
- (4) Be aware of your own feelings of grief/loss inorder to effectively help the bereaved.
ii) Seek help from hospital chaplain or family clergy
iii) Permit family to spend time with deceased infant,participate in holding, bathing, dressing; permittingvisitation of family/friends, clergy, & religious rituals.
- iv) Help family to actualize loss by using proper words
- (1) Use "dead" or "died" as opposed to "lost" or"gone"—helps family accept the death by callingit what it is.
- (2) Tell parents sex of baby (if unknown), give optionfor them to name baby (helps them to remember the baby is a special way), but do not impose itupon them. Consider their belief system.
v) Help family to make preparations for disposition ofthe body, whether or not to permit an autopsy, organdonation, & other spiritual rituals, funeral arrangements—offer referrals approved by hospital
Normal/abnormal interactions between mom and baby (Table 22.2):
- Faces infant; makes eye contact; looks & gazes atinfant Maintains proximity (stays close); directs attention to, points to infant Claims infant (identifies 'family traits'); names infant,calls infant by name Smiles at infant Talks, coos, or sings to infant Expresses pride in infant Assigns meaning to infant's actions & sensitively interprets infant's needs Views infant's behaviors in positive light
- Ignores presence of infant; turns away from it Avoids infant; refuses to hold infant when givenopportunity; maintains distance Fails to acknowledge infants unique features Fails to identify similarity to family, fails to put infantin context of family (brother, sister, etc); has difficultynaming Fails to touch infant with more than fingertips; fails toengage in palmar touch Maintains stoicism or frowns at infant Wakes infant when infant is sleeping; handles infant roughly; hurries feeding by moving nipple continuously Expresses pride in infant Expresses disappointment or displeasure in infantRelates infant behavior to recent events Fails to incorporate infant into life Makes no effort to interpret infant's cues/needs Views infants behavior as exploitative, beinguncooperative; views appearance as ugly, distasteful
Can a baby distinguish mom’s voice from others? Can a baby distinguish mom’s smell from others?
a) Yes – babies can distinguish their mother's voice from others & will turn or interact more with mother (andfather); infants are especially responsive to high-pitched voices.
b) Yes – babies can distinguish the scent of their mother because of her breast milk; mother's can distinguishthe scent of their newborns from other children—each has their own scent.
Vaccines in U.S. increase lifespan by…
a) 30 years.
23) What is herd immunity?
a) Aka community immunity
b) A measure of protection from infectious diseases whom arelacking immunity.
c) Applies to diseases that are contagious & infectious (chickenpox, diphtheria, etc)
d) It does not apply to infectious diseases such as tetanus, whichis not contagious
e) Example, if all but one person in a community has immunity for a pathogen, the one who lacks immunity is protected due to lack of exposure & will remain healthy until pathogen is introduced through a carrier.
f) Caveat: if the one lacking immunity is exposed to a personwith active illness, they can (and most likely will) become ill.
g) Vaccination of the community acts as a firewall for those whoare not (infants & immunocompromised)
h) The greater the proportion of individuals who are resistant, the smaller the probability that a susceptible individual will comeinto contact with an infectious individual
What are thimerosal vaccines?
a) Thimerosal is generally used in multi-dose vial vaccines—vaccinevials that contain multiple doses have a greater risk for theintroduction of microorganism due to frequency of vial use &potential for poor aseptic technique.
b) Thimerosal is only found in multi-dose flu vaccines
c) Since 2001, no new vaccine licensed by FDA for use in children hascontained thimerosal as a preservative, and all vaccines routinelyrecommended by CDC for children younger than 6 years of agehave been thimerosal-free, or contain only trace amounts of thimerosal, except for multi-dose formulations ofinfluenza vaccine. The most recent and rigorous scientific research does not support the argument thatthimerosal-containing vaccines are harmful. However, CDC and FDA continually evaluate new scientificinformation about the safety of vaccines. (http://www.cdc.gov/flu/protect/vaccine/thimerosal.htm)
Postpartum blues– transient symptoms
=> Peaks around 5th day, subsides by 10th day;disappears spontaneously
=>Depression, Let Down Feeling, Restlessness, Fatigue, Insomina, Headache , Anxiety, Sadness, Anger
**Postpartum depression – prolonged affective disorder; symptoms are that of:
depression, Despondency, uncontrollable sobbing, Intense fear, Mood swings, Irritability (Distinguishing Feature), Rejection of infant (prominent feature);Obsessive thoughts of harming infant, alarm & frighten patient., Panic attacks, Severe anxiety, Intense, profound sadness, Anger,
=> More persistent, lasting beyond first weeks after delivery; rarely disappears spontaneously—requires outside help.Resolves within 6 months but differsfrom patient to patient.
**Postpartum psychosis – severe & varied affective disorders occurring in first year postpartum.
=> Extreme depression & tearfulness, Thoughts of harming baby or self, Delusions, Fatigue, Insomnia & restlessness; Suspiciousness,confusion, incoherence, irrationalstatements, obsessive concern for baby, Hallucinations—auditory command toharm infant; infant possessed by devil; command to kill infant;Bipolar Disorder
=> Can begin days after birth; mean onset is 2-3 weeks; requires intervention; will notresolve spontaneously