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Chapter 22--Processes & Stages of Labor and Birth. Critical Factors In Labor. The Four P’s: passage, passenger, powers & psyche Passage : adequate pelvis? cephalopelvic disproportion (CPD) Suspect if presenting part does not engage in pelvis (0 station). Passenger. - PowerPoint PPT Presentation
Citation preview
Chapter 22--Processes amp Stages of Labor and Birth
Critical Factors In Labor
bull The Four Prsquos passage passenger powers amp psyche
bull Passage bull adequate pelvisbull cephalopelvic disproportion (CPD)
bull Suspect if presenting part does not engage in pelvis (0 station)
Passenger
bull The fetus head is largest diameterbull Fetal head 4 bones with 3 membranous
interspaces (sutures) that allow bones to move amp overlap to diminish size of skullbull Molding head becomes narrower longer
sutures can overlap--normal--resolves 1-2 days after birth
bull Fontanelles at junctures of skull bones
Fetal Attitude
Fetal Lie and Presentation
bull Leopolds maneuversUSbull Longitudinal lie Vertical
bull Presenting part bull cephalic (head)
bull vertex (occiput) chin (mentum) bull breech (buttocks or feet) (c-section)
bull sacrumbull Transverse lie Horizontal
(c-section)bull Presenting part shoulder (acromion)
Fetal position bull momrsquos
pelvis is divided into 4 quadrants RA RP LA LP
bull determine which quadrant presenting part (occiput) is pointing towards
Passengerbull Occiput Anterior (LOA amp ROA) most
common positions amp easiest for birth
bull Occiput Posterior (LOP amp ROP) bull can prolong both 1st amp 2nd stage of laborbull back pain during UCs (back labor)bull Instruct partner in sacral pressure during UCrsquosbull Try ldquoall foursrdquo knee-chest or alternate side-
lying positions to encourage baby to rotate to anterior position
Powersbull Contractions supplied by fundus of uterus
bull Involuntary become stronger as labor progresses
bull Abdominal muscles ldquopushingrdquo by mom (2nd stage)
Psychebull Psychological state amp feelings of mom
bull Coping skillsbull Anxiety fear stressbull Labor support
Onset of laborbull Usually begins between 38 amp 42 weeksbull Mechanism is unknownbull Upper uterus contracts downward pushing
presenting part on cervix causing effacement and dilatation
bull Premonitory signs of laborbull Lightening Braxton-Hicks contractions (false
labor)bull cervical changes (ripening) bull bloody show (mucous plug) bull rupture of membranes (ROM) bull sudden burst of energy
False vs True Labor Contractions
False Labor bull Benign and
irregular contractions
bull Felt first abdominally and remain confined to the abdomen and groin
bull Often disappear with ambulation and sleep
bull Do not increase in duration frequency or intensity
True Laborbull Begin irregularly but
become regular and predictable
bull Felt first in lower back and sweep around to the abdomen in a wave
bull Continue no matter what the womenrsquos level of activity
bull Increase in duration frequency and intensity
False vs True Labor Cervix
False Laborbull No significant
change in dilation or effacement
bull No significant bloody show
bull Fetus- presenting part is not engaged in pelvis
True Laborbull Progressive
change in dilation and effacement
bull Bloody show
bull Presenting part engages in pelvis
Critical Thinkingbull A primigravida client has just arrived in the birthing
unit What steps would be most important for the nurse to perform to gain an understanding of the physical status of the client and her fetus
A Check for ruptured membranes and apply a fetal scalp electrode
B Auscultate the fetal heart rate between and during contractions C Palpate contractions and resting uterine tone D Perform a vaginal exam for cervical dilation and perform
Leopolds maneuvers E Determine gestational age of fetus
Stages of Labor First Stage
bull 0 to 10 cm dilatation--opening of cervix)bull Latent slowest part of the process--slow
dilation mild contractionsbull from onset of regular UCs to rapid
dilatation (about 3-4 cms)bull Active labor ldquopicks up steamrdquo--period of
more rapid dilationbull from 4 cm to full dilatation stronger UCsbull Transition 7-10 cm--intense NV shaking
EffacementThinning of cervix(in )
StationDescent of fetal head(in cm)
Descent offetal head
Station
Floating
Engaged
At outletcrowning
Dilatation amp Effacement
Care of Laboring PatientEarly Labor
bull Initial physical assessment amp history
bull Admission--rapportbull Fetal amp UC
monitoringbull Vaginal exams q 2
hoursbull Vital signsbull Temperature q 4
hours-intact or q 2 hours ROM
bull Educate regarding labor
bull Encourage comfort position changes bladder emptying
bull Assess pain pain tolerance preferred type of labordelivery
bull Reassure regarding what is normal reduce anxiety
Couple excited talkative pain is manageable
Care of Laboring Patient Active Labor
bull Transition (7-10 cm) Yikes ldquoout of controlrdquo shaking nauseavomiting sweating pain is intensebull Prepare for delivery
bull Second stage (Pushing)bull Educateinstruct regarding pushingbull Assess urge to push and fetal descentbull Encouragemotivate patient assess fatiguebull Monitor fetalmaternal response to pushing
bulge crowningbull Signs of imminent birth perineal bulging
Couple quieter discouraged pain increasing
Stages of LaborSecond Stage
bull Pushing amp descent of baby (STATION)bull Full dilatation (10 cm) to birth
bull Important NOT to push until full dilationbull Assessment Urge to push Rectal
pressurebull Push only with UCrsquosbull Crowning babyrsquos head is visible at the
opening of vaginabull Cardinal movements of labor
youtubecomwatchv=Xath6kOf0NEampfeature=related youtubecomwatchv=duPxBXN4qMgampfeature=related
Mechanisms of labor A B Descent C Internal rotation D Extension E External rotation
Head Rotation during Descent
Crowning
In the hospital
Alternative settings
Crowning
Stages of Labor Third Stage
bull Placental stage from birth to delivery of placenta
bull Placental separation from uterine wall (rise of fundus sudden gush of blood lengthening of umbilical cord)
bull Entire lining of uterus shedbull Expulsion of placenta
bull Normal blood loss 300-500 mLbull If placenta does not deliver spontaneously can
be delivered manuallybull Pitocin infusion started immediately post
delivery of placenta
Critical Thinkingbull
A client is admitted to the labor unit with contractions 2 to 3 minutes apart and lasting 60 to 90 seconds The client is apprehensive and vomiting This nurse understands this information to indicate that the client is most likely in what phase of labor
bull A) Active bull B) Transition bull C) Latent bull D) Second
Chapter 23Intrapartal Nursing Assessment
Initial Intrapartum AssessmentPages 608-612
bull Vital signsbull Fetal heart rate pattern fetal distressbull Contraction pattern intensity painbull Membrane status--intact ruptured nitrizine test
amniotic fluid clear meconium foul odorbull Prenatal records history of pregnancy
complications previous pregnancies and deliveries maternal health problems
bull Psychosocialfamilycultural issuesbull Labs CBC dip urine for protein glucose
ketonesbull Vaginal Exam--effacementdilationstation fetal
presentationlie Assesses LABOR PROGRESS
Intrauterine Fetal Resuscitation
bull Stop pitocinbull Reposition to left lateral Trendelenberg if neededbull Oxygen via mask at 8-10 Lminbull Increase IV fluidsbull SQ terbutaline (025 mg) if uterus not relaxingbull Vaginal exam for possible cause prolapse fetal
descent rupture abruptionbull Amnioinfusion for variable decelsbull Notify MDmidwife
Which strip shows signs thatImmediate intervention is needed Why What would you do
A
B
Experiences of Painbull Etiology bull Physiologybull Perception
bull Factors influencingAnxiety Psychological factorsExpectations Cultural factorsSupport Fetal position
Comfort and Pain Relief
bull Support from doula or coachbull Alternative therapies
bullRelaxationmassagebull Focusing and imagerybullBreathingbullHerbal preparationsaromatherapybullHypnosis
Comfort and Pain Reliefbull Pharmacological Measures
bullNarcotic analgesicsbullNubainStadolDemerol (pg 689)
bullRegional nerve blocksbullEpiduralspinal
bull Local anesthetic blocksbullPudendalperineal
Systemic AnalgesiaTable 25-3 pg 690
bull Pre-medication Assessment bull Pain level VS allergies drug dependence
(withdrawal) vaginal examprogress in labor UC pattern fetal heart rate tracing
bull Post-medication Assessmentbull VS esp RR LOC dizziness (bedpan)
sedation FHRbull Reversal agent Naloxone (Narcan)
bull Competes with narcotic for opiate receptors Used in both mom and baby (avoid with narcotic dependence)
Regional Anesthesiabull Injection of local anesthesia to block
specific nerve pathwaysbull Epiduralspinal anesthesia
bullSystemic toxicity cardiovascular collapsebullSide effects Hypotension (preload with IV
fluids) fetal distress on FHR tracing spinal HA
bullContradindications coagulation disorders low platelet count (lt 100) allergy neurologic disease aspirin use
bullNursing care Preload IV fluids (LR) monitor BP HR anesthesia level FHR foley cath maternal positioning
Epidural Anesthesia
Medication for Pain Relief Birthbull Local anesthesia
bull Pudendal nerve block (2nd stage episiotomy repair)bull Local infiltration in perineum (episiotomy repair)
bull General anesthesiabull Regional contraindicatedemergencybull Preparation hip wedge preoxygenation cricoid
pressure for intubationbull Complications fetal depression aspiration of
vomitus (Bicitra)
Local anesthesia for Episiotomy
Childbirth at Risk (Ch 26)
Complications of Labor or Delivery
Critical Thinking The client in active labor is requesting pain relief The
physician orders epidural anesthesia for the client Which of the following parameters should the nurse
be prepared to assess immediately after administration of the epidural
bull A) For headache bull B) For urinary retention bull C) The blood pressure bull D) The maternal pulse rate
Precipitous Labor amp Birthbull Labor in lt 3 hoursbull Risk factors
bull Multiparity oxytocin or amniotomy hx of precipitate labor
bull Risks for injurybull Maternal cervical vaginal amp perineal
lacerations with possible hemorrhage pain anxiety
bull Fetal Birth trauma (intracranial bleed brachial palsy) meconium-stained fluid fetal distress
bull Management close monitoring for cervical changes induction
Postterm Pregnancybull gt 42 weeksbull Maternal risks traumahemorrhage due
to larger baby uarroperative deliveryc-section
bull Fetal risks placental changes that darroxygenation to baby and uarrmortality rate oligohydramnios (uarrcord compression during labor) LGA baby (uarrbirth trauma shoulder dystocia) meconium aspiration
bull Management gt 40 wks NST BPP or modified BPP (NST amp AFI) induction
Malpresentationsbull Occiput-posterior (OP)
bull Prolonged labor back labor (sacral nerve compression) arrested dilatation descent perineal tears
bull Usually vaginal but may need C-Section if baby doesnrsquot rotate
bull Management positioning (side-lying knee-chest or hand-knees) sacral pressure during UCrsquos
bull Transverse Liebull Associated with pendulous abdomen uterine
massesfibroids congenital abnormalities of uterus hydramnios
bull Attempt External Cephalic Version if unsuccessful obligatory C-section
Malpresentations (cont)bull Breech presentation
Assessment FHT heard high on the abdomen Leopoldrsquos vaginal exam amp USbull Higher risk of anoxia from prolapsed cord traumatic injury to
the after coming head fracture of spine or arm dysfunctional labor
bull Usually delivered by C-section
External Versionbull External cephalic version (37-38 wks) abdominal
manipulation to change fetal presentationbull Contraindications multiple gestation fetal
breech is engaged in pelvis oligohydramnios nonreactive NST nuchal cord vaginal bleeding IUGR ROM
bull Risks immediate cesarean birthbull Nursing actions NPO 8 hrs NST IV line
terbutaline continuous FHR US used to guide manipulations assess for labor fetal distress O- moms need Rhogam following the procedure
MacrosomiaShoulder Dystociabull Wt gt 4500 gms (9-10 lbs)bull Associated with
bull DM Gestational DM Multiparity Postdates obesitybull Risks
bull Shoulder dystocia difficulty delivering the shoulders after head is delivered (obstetrical emergency)
bull Maternal vaginalcervical tears pp hemorrhage rupturebull Fetal compressed cord fractured clavical asphyxia amp neurologic
damage brachial plexus injury (ErbrsquosPalsy)bull SS Turtle signbull Nursing interventions McRoberts maneuvers suprapubic
pressure PP assess for uterine atonyhemorrhage trauma cerebral or neurologic damage to baby
Video youtubecomwatchv=jV6g427UMxYampfeature=related
McRoberts Maneuvers Video
Multiple Gestationbull Monozygotic (identical) twins can have 1 or 2 placentas
chorions or amnions (uarrrisk if all shared)bull Dizygotic (fraternal) twins 2 of everything
bull Dx faster than usual growth of uterus uarrAFP HCG Ultrasound
bull Risks bull Maternal SAB gestational DM HTNpreeclampsiaHELLP
hydramnios PT labor amp deliverybull Fetal Preterm birth twin-to-twin transfusion
Multiple Gestation (cont)bull Management
bull US to determine what type of twinsbull Prevention of PT laborroutine cervical measurements
(US)bull NST surveillance bull Birth depends on maternal amp fetal complications and
fetal position presentationbull Examination of placentabull Close monitoring PP for hemorrhage (atony)
Abruptio Placentaebull Premature separation of placenta from uterine wallbull SS sharp stabbing pain high in fundus heavy
bleeding (may be occult) hard board-like uterus tense painful uterus signs of shock due to blood loss Port-Wine aminotic fluid if ROM
bull Predisposing fx uarrparity adv maternal age short umbilical cord chronic HTN PIH direct trauma vasoconstriction from cocaine or cigarette use
bull Fetal distress on monitor Can progress to DIC
Abruptio Placentae (cont)bull Management
bull Emergency Immediate c-section if birth not imminent
bull Lg gauge IV bull O2 via mask fetal monitoring
maternal VS lateral positioning labs blood transfusion (have 2 units avail)
bull CBC (HampH) Fibrinogen levels platelet count PTPTT fibrin degradation products ( sx of DIC)
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
for pp hemorrhage
bull Table 26-6 pg 746 differential dx abruptioprevia
Low-lying Marginal
Partial Complete
Placenta Previas
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
Diabetes Pulmonary disease Pregnancy-induced hypertension)
bull Chorioamnionitisbull Suspected fetal problems- Intrauterine Growth
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Inductionbull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessmentbull Bishop Score- rating that determines if the cervix
is ready for induction--Pg 765bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole -Inadequate uterine relaxation between contractions lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveriesbull Forceps
bull Indications unable to push arrested descent need a quick delivery breech
bull Associated with maternalfetal birth trauma rectal sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
laborbull Elective
Placenta Factorsbull Placenta previabull Placental abruptionbull Umbilical cord prolapse
Fetal Factorsbull Breech transverse liebull Macrosomiabull Extreme low birth wtbull Fetal distressbull Fetal anomaliesbull Multiple gestation
Cesarean Birth (cont)bull Mortality
morbiditybull 4 x higher than
vaginal birth in US Most risk assoc with emergency c-section
bull Incisionbull Skin vs uterinebull Classical vs low
transverse
bull Maternal Complicationsbull Infectionbull Anesthesia reactionsbull DeepVeinThrombopheb
itisbull Bleedingbull Ureteralbladder injurybull Increase risk for
subsequent pregnancybull Placenta AcretaPrevia
Infertility
Cesarean Birthbull Pre-op CBC w platelets hold clotbull bicitraantacidbull monitor babybull Teaching pre amp post-op anesthesia recovery
breastfeedingbull Psychosocial issues
bull Fearbull Self-imageself-esteem
Post-Op Carebull Assess fundusbleeding vital signs DVTbull Antibiotics bull Pain Duramorph Breakthrough pain
meds Benadryl for itching Zofran for nausea
bull Clear liquids and advance as toleratedbull Assess for GI function Bowel sounds
Passing flatusbull Ambulation Pre-medicate teach splinting
with pillowbull Stool softener
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
multiparity excessive analgesia Afterpains wwwyoutubecomwatchv=EbItF_7KYCcampfeature=related
Fundal Assessment Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina Cervix returns to firm nongravid consistency
by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum Assessment turn pt to side in Simrsquos
position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments Constipation Give stool softeners as
ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis Superficial leg vein disease
ndash Ss tenderness in portion of vein local heat amp redness normal temperature or low-grade fever
ndash Tx local heat elevate limb bed rest analgesia elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation Engorgement day 3 or 4
ndash If breastfeeding Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
Postpartum Complications Postpartum Hemorrhage
ndash CAUSES Uterine atony lacerations retained placental fragments
Risk factorsndash uarr uterine distension multiples polyhydramnios
macrosomia fibroidsndash Trauma rapid or operative birthndash Placental problems previa accreta abruptio
retained placental fragmentsndash Atonic uterus prolonged pitocin magnesium
sulfate or labor uarr maternal age or parity uterine scar chorioamnionitis anemia prior history
ndash Inadequate blood coagulation fetal death or DIC
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
Critical Factors In Labor
bull The Four Prsquos passage passenger powers amp psyche
bull Passage bull adequate pelvisbull cephalopelvic disproportion (CPD)
bull Suspect if presenting part does not engage in pelvis (0 station)
Passenger
bull The fetus head is largest diameterbull Fetal head 4 bones with 3 membranous
interspaces (sutures) that allow bones to move amp overlap to diminish size of skullbull Molding head becomes narrower longer
sutures can overlap--normal--resolves 1-2 days after birth
bull Fontanelles at junctures of skull bones
Fetal Attitude
Fetal Lie and Presentation
bull Leopolds maneuversUSbull Longitudinal lie Vertical
bull Presenting part bull cephalic (head)
bull vertex (occiput) chin (mentum) bull breech (buttocks or feet) (c-section)
bull sacrumbull Transverse lie Horizontal
(c-section)bull Presenting part shoulder (acromion)
Fetal position bull momrsquos
pelvis is divided into 4 quadrants RA RP LA LP
bull determine which quadrant presenting part (occiput) is pointing towards
Passengerbull Occiput Anterior (LOA amp ROA) most
common positions amp easiest for birth
bull Occiput Posterior (LOP amp ROP) bull can prolong both 1st amp 2nd stage of laborbull back pain during UCs (back labor)bull Instruct partner in sacral pressure during UCrsquosbull Try ldquoall foursrdquo knee-chest or alternate side-
lying positions to encourage baby to rotate to anterior position
Powersbull Contractions supplied by fundus of uterus
bull Involuntary become stronger as labor progresses
bull Abdominal muscles ldquopushingrdquo by mom (2nd stage)
Psychebull Psychological state amp feelings of mom
bull Coping skillsbull Anxiety fear stressbull Labor support
Onset of laborbull Usually begins between 38 amp 42 weeksbull Mechanism is unknownbull Upper uterus contracts downward pushing
presenting part on cervix causing effacement and dilatation
bull Premonitory signs of laborbull Lightening Braxton-Hicks contractions (false
labor)bull cervical changes (ripening) bull bloody show (mucous plug) bull rupture of membranes (ROM) bull sudden burst of energy
False vs True Labor Contractions
False Labor bull Benign and
irregular contractions
bull Felt first abdominally and remain confined to the abdomen and groin
bull Often disappear with ambulation and sleep
bull Do not increase in duration frequency or intensity
True Laborbull Begin irregularly but
become regular and predictable
bull Felt first in lower back and sweep around to the abdomen in a wave
bull Continue no matter what the womenrsquos level of activity
bull Increase in duration frequency and intensity
False vs True Labor Cervix
False Laborbull No significant
change in dilation or effacement
bull No significant bloody show
bull Fetus- presenting part is not engaged in pelvis
True Laborbull Progressive
change in dilation and effacement
bull Bloody show
bull Presenting part engages in pelvis
Critical Thinkingbull A primigravida client has just arrived in the birthing
unit What steps would be most important for the nurse to perform to gain an understanding of the physical status of the client and her fetus
A Check for ruptured membranes and apply a fetal scalp electrode
B Auscultate the fetal heart rate between and during contractions C Palpate contractions and resting uterine tone D Perform a vaginal exam for cervical dilation and perform
Leopolds maneuvers E Determine gestational age of fetus
Stages of Labor First Stage
bull 0 to 10 cm dilatation--opening of cervix)bull Latent slowest part of the process--slow
dilation mild contractionsbull from onset of regular UCs to rapid
dilatation (about 3-4 cms)bull Active labor ldquopicks up steamrdquo--period of
more rapid dilationbull from 4 cm to full dilatation stronger UCsbull Transition 7-10 cm--intense NV shaking
EffacementThinning of cervix(in )
StationDescent of fetal head(in cm)
Descent offetal head
Station
Floating
Engaged
At outletcrowning
Dilatation amp Effacement
Care of Laboring PatientEarly Labor
bull Initial physical assessment amp history
bull Admission--rapportbull Fetal amp UC
monitoringbull Vaginal exams q 2
hoursbull Vital signsbull Temperature q 4
hours-intact or q 2 hours ROM
bull Educate regarding labor
bull Encourage comfort position changes bladder emptying
bull Assess pain pain tolerance preferred type of labordelivery
bull Reassure regarding what is normal reduce anxiety
Couple excited talkative pain is manageable
Care of Laboring Patient Active Labor
bull Transition (7-10 cm) Yikes ldquoout of controlrdquo shaking nauseavomiting sweating pain is intensebull Prepare for delivery
bull Second stage (Pushing)bull Educateinstruct regarding pushingbull Assess urge to push and fetal descentbull Encouragemotivate patient assess fatiguebull Monitor fetalmaternal response to pushing
bulge crowningbull Signs of imminent birth perineal bulging
Couple quieter discouraged pain increasing
Stages of LaborSecond Stage
bull Pushing amp descent of baby (STATION)bull Full dilatation (10 cm) to birth
bull Important NOT to push until full dilationbull Assessment Urge to push Rectal
pressurebull Push only with UCrsquosbull Crowning babyrsquos head is visible at the
opening of vaginabull Cardinal movements of labor
youtubecomwatchv=Xath6kOf0NEampfeature=related youtubecomwatchv=duPxBXN4qMgampfeature=related
Mechanisms of labor A B Descent C Internal rotation D Extension E External rotation
Head Rotation during Descent
Crowning
In the hospital
Alternative settings
Crowning
Stages of Labor Third Stage
bull Placental stage from birth to delivery of placenta
bull Placental separation from uterine wall (rise of fundus sudden gush of blood lengthening of umbilical cord)
bull Entire lining of uterus shedbull Expulsion of placenta
bull Normal blood loss 300-500 mLbull If placenta does not deliver spontaneously can
be delivered manuallybull Pitocin infusion started immediately post
delivery of placenta
Critical Thinkingbull
A client is admitted to the labor unit with contractions 2 to 3 minutes apart and lasting 60 to 90 seconds The client is apprehensive and vomiting This nurse understands this information to indicate that the client is most likely in what phase of labor
bull A) Active bull B) Transition bull C) Latent bull D) Second
Chapter 23Intrapartal Nursing Assessment
Initial Intrapartum AssessmentPages 608-612
bull Vital signsbull Fetal heart rate pattern fetal distressbull Contraction pattern intensity painbull Membrane status--intact ruptured nitrizine test
amniotic fluid clear meconium foul odorbull Prenatal records history of pregnancy
complications previous pregnancies and deliveries maternal health problems
bull Psychosocialfamilycultural issuesbull Labs CBC dip urine for protein glucose
ketonesbull Vaginal Exam--effacementdilationstation fetal
presentationlie Assesses LABOR PROGRESS
Intrauterine Fetal Resuscitation
bull Stop pitocinbull Reposition to left lateral Trendelenberg if neededbull Oxygen via mask at 8-10 Lminbull Increase IV fluidsbull SQ terbutaline (025 mg) if uterus not relaxingbull Vaginal exam for possible cause prolapse fetal
descent rupture abruptionbull Amnioinfusion for variable decelsbull Notify MDmidwife
Which strip shows signs thatImmediate intervention is needed Why What would you do
A
B
Experiences of Painbull Etiology bull Physiologybull Perception
bull Factors influencingAnxiety Psychological factorsExpectations Cultural factorsSupport Fetal position
Comfort and Pain Relief
bull Support from doula or coachbull Alternative therapies
bullRelaxationmassagebull Focusing and imagerybullBreathingbullHerbal preparationsaromatherapybullHypnosis
Comfort and Pain Reliefbull Pharmacological Measures
bullNarcotic analgesicsbullNubainStadolDemerol (pg 689)
bullRegional nerve blocksbullEpiduralspinal
bull Local anesthetic blocksbullPudendalperineal
Systemic AnalgesiaTable 25-3 pg 690
bull Pre-medication Assessment bull Pain level VS allergies drug dependence
(withdrawal) vaginal examprogress in labor UC pattern fetal heart rate tracing
bull Post-medication Assessmentbull VS esp RR LOC dizziness (bedpan)
sedation FHRbull Reversal agent Naloxone (Narcan)
bull Competes with narcotic for opiate receptors Used in both mom and baby (avoid with narcotic dependence)
Regional Anesthesiabull Injection of local anesthesia to block
specific nerve pathwaysbull Epiduralspinal anesthesia
bullSystemic toxicity cardiovascular collapsebullSide effects Hypotension (preload with IV
fluids) fetal distress on FHR tracing spinal HA
bullContradindications coagulation disorders low platelet count (lt 100) allergy neurologic disease aspirin use
bullNursing care Preload IV fluids (LR) monitor BP HR anesthesia level FHR foley cath maternal positioning
Epidural Anesthesia
Medication for Pain Relief Birthbull Local anesthesia
bull Pudendal nerve block (2nd stage episiotomy repair)bull Local infiltration in perineum (episiotomy repair)
bull General anesthesiabull Regional contraindicatedemergencybull Preparation hip wedge preoxygenation cricoid
pressure for intubationbull Complications fetal depression aspiration of
vomitus (Bicitra)
Local anesthesia for Episiotomy
Childbirth at Risk (Ch 26)
Complications of Labor or Delivery
Critical Thinking The client in active labor is requesting pain relief The
physician orders epidural anesthesia for the client Which of the following parameters should the nurse
be prepared to assess immediately after administration of the epidural
bull A) For headache bull B) For urinary retention bull C) The blood pressure bull D) The maternal pulse rate
Precipitous Labor amp Birthbull Labor in lt 3 hoursbull Risk factors
bull Multiparity oxytocin or amniotomy hx of precipitate labor
bull Risks for injurybull Maternal cervical vaginal amp perineal
lacerations with possible hemorrhage pain anxiety
bull Fetal Birth trauma (intracranial bleed brachial palsy) meconium-stained fluid fetal distress
bull Management close monitoring for cervical changes induction
Postterm Pregnancybull gt 42 weeksbull Maternal risks traumahemorrhage due
to larger baby uarroperative deliveryc-section
bull Fetal risks placental changes that darroxygenation to baby and uarrmortality rate oligohydramnios (uarrcord compression during labor) LGA baby (uarrbirth trauma shoulder dystocia) meconium aspiration
bull Management gt 40 wks NST BPP or modified BPP (NST amp AFI) induction
Malpresentationsbull Occiput-posterior (OP)
bull Prolonged labor back labor (sacral nerve compression) arrested dilatation descent perineal tears
bull Usually vaginal but may need C-Section if baby doesnrsquot rotate
bull Management positioning (side-lying knee-chest or hand-knees) sacral pressure during UCrsquos
bull Transverse Liebull Associated with pendulous abdomen uterine
massesfibroids congenital abnormalities of uterus hydramnios
bull Attempt External Cephalic Version if unsuccessful obligatory C-section
Malpresentations (cont)bull Breech presentation
Assessment FHT heard high on the abdomen Leopoldrsquos vaginal exam amp USbull Higher risk of anoxia from prolapsed cord traumatic injury to
the after coming head fracture of spine or arm dysfunctional labor
bull Usually delivered by C-section
External Versionbull External cephalic version (37-38 wks) abdominal
manipulation to change fetal presentationbull Contraindications multiple gestation fetal
breech is engaged in pelvis oligohydramnios nonreactive NST nuchal cord vaginal bleeding IUGR ROM
bull Risks immediate cesarean birthbull Nursing actions NPO 8 hrs NST IV line
terbutaline continuous FHR US used to guide manipulations assess for labor fetal distress O- moms need Rhogam following the procedure
MacrosomiaShoulder Dystociabull Wt gt 4500 gms (9-10 lbs)bull Associated with
bull DM Gestational DM Multiparity Postdates obesitybull Risks
bull Shoulder dystocia difficulty delivering the shoulders after head is delivered (obstetrical emergency)
bull Maternal vaginalcervical tears pp hemorrhage rupturebull Fetal compressed cord fractured clavical asphyxia amp neurologic
damage brachial plexus injury (ErbrsquosPalsy)bull SS Turtle signbull Nursing interventions McRoberts maneuvers suprapubic
pressure PP assess for uterine atonyhemorrhage trauma cerebral or neurologic damage to baby
Video youtubecomwatchv=jV6g427UMxYampfeature=related
McRoberts Maneuvers Video
Multiple Gestationbull Monozygotic (identical) twins can have 1 or 2 placentas
chorions or amnions (uarrrisk if all shared)bull Dizygotic (fraternal) twins 2 of everything
bull Dx faster than usual growth of uterus uarrAFP HCG Ultrasound
bull Risks bull Maternal SAB gestational DM HTNpreeclampsiaHELLP
hydramnios PT labor amp deliverybull Fetal Preterm birth twin-to-twin transfusion
Multiple Gestation (cont)bull Management
bull US to determine what type of twinsbull Prevention of PT laborroutine cervical measurements
(US)bull NST surveillance bull Birth depends on maternal amp fetal complications and
fetal position presentationbull Examination of placentabull Close monitoring PP for hemorrhage (atony)
Abruptio Placentaebull Premature separation of placenta from uterine wallbull SS sharp stabbing pain high in fundus heavy
bleeding (may be occult) hard board-like uterus tense painful uterus signs of shock due to blood loss Port-Wine aminotic fluid if ROM
bull Predisposing fx uarrparity adv maternal age short umbilical cord chronic HTN PIH direct trauma vasoconstriction from cocaine or cigarette use
bull Fetal distress on monitor Can progress to DIC
Abruptio Placentae (cont)bull Management
bull Emergency Immediate c-section if birth not imminent
bull Lg gauge IV bull O2 via mask fetal monitoring
maternal VS lateral positioning labs blood transfusion (have 2 units avail)
bull CBC (HampH) Fibrinogen levels platelet count PTPTT fibrin degradation products ( sx of DIC)
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
for pp hemorrhage
bull Table 26-6 pg 746 differential dx abruptioprevia
Low-lying Marginal
Partial Complete
Placenta Previas
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
Diabetes Pulmonary disease Pregnancy-induced hypertension)
bull Chorioamnionitisbull Suspected fetal problems- Intrauterine Growth
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Inductionbull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessmentbull Bishop Score- rating that determines if the cervix
is ready for induction--Pg 765bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole -Inadequate uterine relaxation between contractions lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveriesbull Forceps
bull Indications unable to push arrested descent need a quick delivery breech
bull Associated with maternalfetal birth trauma rectal sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
laborbull Elective
Placenta Factorsbull Placenta previabull Placental abruptionbull Umbilical cord prolapse
Fetal Factorsbull Breech transverse liebull Macrosomiabull Extreme low birth wtbull Fetal distressbull Fetal anomaliesbull Multiple gestation
Cesarean Birth (cont)bull Mortality
morbiditybull 4 x higher than
vaginal birth in US Most risk assoc with emergency c-section
bull Incisionbull Skin vs uterinebull Classical vs low
transverse
bull Maternal Complicationsbull Infectionbull Anesthesia reactionsbull DeepVeinThrombopheb
itisbull Bleedingbull Ureteralbladder injurybull Increase risk for
subsequent pregnancybull Placenta AcretaPrevia
Infertility
Cesarean Birthbull Pre-op CBC w platelets hold clotbull bicitraantacidbull monitor babybull Teaching pre amp post-op anesthesia recovery
breastfeedingbull Psychosocial issues
bull Fearbull Self-imageself-esteem
Post-Op Carebull Assess fundusbleeding vital signs DVTbull Antibiotics bull Pain Duramorph Breakthrough pain
meds Benadryl for itching Zofran for nausea
bull Clear liquids and advance as toleratedbull Assess for GI function Bowel sounds
Passing flatusbull Ambulation Pre-medicate teach splinting
with pillowbull Stool softener
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
multiparity excessive analgesia Afterpains wwwyoutubecomwatchv=EbItF_7KYCcampfeature=related
Fundal Assessment Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina Cervix returns to firm nongravid consistency
by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum Assessment turn pt to side in Simrsquos
position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments Constipation Give stool softeners as
ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis Superficial leg vein disease
ndash Ss tenderness in portion of vein local heat amp redness normal temperature or low-grade fever
ndash Tx local heat elevate limb bed rest analgesia elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation Engorgement day 3 or 4
ndash If breastfeeding Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
Postpartum Complications Postpartum Hemorrhage
ndash CAUSES Uterine atony lacerations retained placental fragments
Risk factorsndash uarr uterine distension multiples polyhydramnios
macrosomia fibroidsndash Trauma rapid or operative birthndash Placental problems previa accreta abruptio
retained placental fragmentsndash Atonic uterus prolonged pitocin magnesium
sulfate or labor uarr maternal age or parity uterine scar chorioamnionitis anemia prior history
ndash Inadequate blood coagulation fetal death or DIC
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
Passenger
bull The fetus head is largest diameterbull Fetal head 4 bones with 3 membranous
interspaces (sutures) that allow bones to move amp overlap to diminish size of skullbull Molding head becomes narrower longer
sutures can overlap--normal--resolves 1-2 days after birth
bull Fontanelles at junctures of skull bones
Fetal Attitude
Fetal Lie and Presentation
bull Leopolds maneuversUSbull Longitudinal lie Vertical
bull Presenting part bull cephalic (head)
bull vertex (occiput) chin (mentum) bull breech (buttocks or feet) (c-section)
bull sacrumbull Transverse lie Horizontal
(c-section)bull Presenting part shoulder (acromion)
Fetal position bull momrsquos
pelvis is divided into 4 quadrants RA RP LA LP
bull determine which quadrant presenting part (occiput) is pointing towards
Passengerbull Occiput Anterior (LOA amp ROA) most
common positions amp easiest for birth
bull Occiput Posterior (LOP amp ROP) bull can prolong both 1st amp 2nd stage of laborbull back pain during UCs (back labor)bull Instruct partner in sacral pressure during UCrsquosbull Try ldquoall foursrdquo knee-chest or alternate side-
lying positions to encourage baby to rotate to anterior position
Powersbull Contractions supplied by fundus of uterus
bull Involuntary become stronger as labor progresses
bull Abdominal muscles ldquopushingrdquo by mom (2nd stage)
Psychebull Psychological state amp feelings of mom
bull Coping skillsbull Anxiety fear stressbull Labor support
Onset of laborbull Usually begins between 38 amp 42 weeksbull Mechanism is unknownbull Upper uterus contracts downward pushing
presenting part on cervix causing effacement and dilatation
bull Premonitory signs of laborbull Lightening Braxton-Hicks contractions (false
labor)bull cervical changes (ripening) bull bloody show (mucous plug) bull rupture of membranes (ROM) bull sudden burst of energy
False vs True Labor Contractions
False Labor bull Benign and
irregular contractions
bull Felt first abdominally and remain confined to the abdomen and groin
bull Often disappear with ambulation and sleep
bull Do not increase in duration frequency or intensity
True Laborbull Begin irregularly but
become regular and predictable
bull Felt first in lower back and sweep around to the abdomen in a wave
bull Continue no matter what the womenrsquos level of activity
bull Increase in duration frequency and intensity
False vs True Labor Cervix
False Laborbull No significant
change in dilation or effacement
bull No significant bloody show
bull Fetus- presenting part is not engaged in pelvis
True Laborbull Progressive
change in dilation and effacement
bull Bloody show
bull Presenting part engages in pelvis
Critical Thinkingbull A primigravida client has just arrived in the birthing
unit What steps would be most important for the nurse to perform to gain an understanding of the physical status of the client and her fetus
A Check for ruptured membranes and apply a fetal scalp electrode
B Auscultate the fetal heart rate between and during contractions C Palpate contractions and resting uterine tone D Perform a vaginal exam for cervical dilation and perform
Leopolds maneuvers E Determine gestational age of fetus
Stages of Labor First Stage
bull 0 to 10 cm dilatation--opening of cervix)bull Latent slowest part of the process--slow
dilation mild contractionsbull from onset of regular UCs to rapid
dilatation (about 3-4 cms)bull Active labor ldquopicks up steamrdquo--period of
more rapid dilationbull from 4 cm to full dilatation stronger UCsbull Transition 7-10 cm--intense NV shaking
EffacementThinning of cervix(in )
StationDescent of fetal head(in cm)
Descent offetal head
Station
Floating
Engaged
At outletcrowning
Dilatation amp Effacement
Care of Laboring PatientEarly Labor
bull Initial physical assessment amp history
bull Admission--rapportbull Fetal amp UC
monitoringbull Vaginal exams q 2
hoursbull Vital signsbull Temperature q 4
hours-intact or q 2 hours ROM
bull Educate regarding labor
bull Encourage comfort position changes bladder emptying
bull Assess pain pain tolerance preferred type of labordelivery
bull Reassure regarding what is normal reduce anxiety
Couple excited talkative pain is manageable
Care of Laboring Patient Active Labor
bull Transition (7-10 cm) Yikes ldquoout of controlrdquo shaking nauseavomiting sweating pain is intensebull Prepare for delivery
bull Second stage (Pushing)bull Educateinstruct regarding pushingbull Assess urge to push and fetal descentbull Encouragemotivate patient assess fatiguebull Monitor fetalmaternal response to pushing
bulge crowningbull Signs of imminent birth perineal bulging
Couple quieter discouraged pain increasing
Stages of LaborSecond Stage
bull Pushing amp descent of baby (STATION)bull Full dilatation (10 cm) to birth
bull Important NOT to push until full dilationbull Assessment Urge to push Rectal
pressurebull Push only with UCrsquosbull Crowning babyrsquos head is visible at the
opening of vaginabull Cardinal movements of labor
youtubecomwatchv=Xath6kOf0NEampfeature=related youtubecomwatchv=duPxBXN4qMgampfeature=related
Mechanisms of labor A B Descent C Internal rotation D Extension E External rotation
Head Rotation during Descent
Crowning
In the hospital
Alternative settings
Crowning
Stages of Labor Third Stage
bull Placental stage from birth to delivery of placenta
bull Placental separation from uterine wall (rise of fundus sudden gush of blood lengthening of umbilical cord)
bull Entire lining of uterus shedbull Expulsion of placenta
bull Normal blood loss 300-500 mLbull If placenta does not deliver spontaneously can
be delivered manuallybull Pitocin infusion started immediately post
delivery of placenta
Critical Thinkingbull
A client is admitted to the labor unit with contractions 2 to 3 minutes apart and lasting 60 to 90 seconds The client is apprehensive and vomiting This nurse understands this information to indicate that the client is most likely in what phase of labor
bull A) Active bull B) Transition bull C) Latent bull D) Second
Chapter 23Intrapartal Nursing Assessment
Initial Intrapartum AssessmentPages 608-612
bull Vital signsbull Fetal heart rate pattern fetal distressbull Contraction pattern intensity painbull Membrane status--intact ruptured nitrizine test
amniotic fluid clear meconium foul odorbull Prenatal records history of pregnancy
complications previous pregnancies and deliveries maternal health problems
bull Psychosocialfamilycultural issuesbull Labs CBC dip urine for protein glucose
ketonesbull Vaginal Exam--effacementdilationstation fetal
presentationlie Assesses LABOR PROGRESS
Intrauterine Fetal Resuscitation
bull Stop pitocinbull Reposition to left lateral Trendelenberg if neededbull Oxygen via mask at 8-10 Lminbull Increase IV fluidsbull SQ terbutaline (025 mg) if uterus not relaxingbull Vaginal exam for possible cause prolapse fetal
descent rupture abruptionbull Amnioinfusion for variable decelsbull Notify MDmidwife
Which strip shows signs thatImmediate intervention is needed Why What would you do
A
B
Experiences of Painbull Etiology bull Physiologybull Perception
bull Factors influencingAnxiety Psychological factorsExpectations Cultural factorsSupport Fetal position
Comfort and Pain Relief
bull Support from doula or coachbull Alternative therapies
bullRelaxationmassagebull Focusing and imagerybullBreathingbullHerbal preparationsaromatherapybullHypnosis
Comfort and Pain Reliefbull Pharmacological Measures
bullNarcotic analgesicsbullNubainStadolDemerol (pg 689)
bullRegional nerve blocksbullEpiduralspinal
bull Local anesthetic blocksbullPudendalperineal
Systemic AnalgesiaTable 25-3 pg 690
bull Pre-medication Assessment bull Pain level VS allergies drug dependence
(withdrawal) vaginal examprogress in labor UC pattern fetal heart rate tracing
bull Post-medication Assessmentbull VS esp RR LOC dizziness (bedpan)
sedation FHRbull Reversal agent Naloxone (Narcan)
bull Competes with narcotic for opiate receptors Used in both mom and baby (avoid with narcotic dependence)
Regional Anesthesiabull Injection of local anesthesia to block
specific nerve pathwaysbull Epiduralspinal anesthesia
bullSystemic toxicity cardiovascular collapsebullSide effects Hypotension (preload with IV
fluids) fetal distress on FHR tracing spinal HA
bullContradindications coagulation disorders low platelet count (lt 100) allergy neurologic disease aspirin use
bullNursing care Preload IV fluids (LR) monitor BP HR anesthesia level FHR foley cath maternal positioning
Epidural Anesthesia
Medication for Pain Relief Birthbull Local anesthesia
bull Pudendal nerve block (2nd stage episiotomy repair)bull Local infiltration in perineum (episiotomy repair)
bull General anesthesiabull Regional contraindicatedemergencybull Preparation hip wedge preoxygenation cricoid
pressure for intubationbull Complications fetal depression aspiration of
vomitus (Bicitra)
Local anesthesia for Episiotomy
Childbirth at Risk (Ch 26)
Complications of Labor or Delivery
Critical Thinking The client in active labor is requesting pain relief The
physician orders epidural anesthesia for the client Which of the following parameters should the nurse
be prepared to assess immediately after administration of the epidural
bull A) For headache bull B) For urinary retention bull C) The blood pressure bull D) The maternal pulse rate
Precipitous Labor amp Birthbull Labor in lt 3 hoursbull Risk factors
bull Multiparity oxytocin or amniotomy hx of precipitate labor
bull Risks for injurybull Maternal cervical vaginal amp perineal
lacerations with possible hemorrhage pain anxiety
bull Fetal Birth trauma (intracranial bleed brachial palsy) meconium-stained fluid fetal distress
bull Management close monitoring for cervical changes induction
Postterm Pregnancybull gt 42 weeksbull Maternal risks traumahemorrhage due
to larger baby uarroperative deliveryc-section
bull Fetal risks placental changes that darroxygenation to baby and uarrmortality rate oligohydramnios (uarrcord compression during labor) LGA baby (uarrbirth trauma shoulder dystocia) meconium aspiration
bull Management gt 40 wks NST BPP or modified BPP (NST amp AFI) induction
Malpresentationsbull Occiput-posterior (OP)
bull Prolonged labor back labor (sacral nerve compression) arrested dilatation descent perineal tears
bull Usually vaginal but may need C-Section if baby doesnrsquot rotate
bull Management positioning (side-lying knee-chest or hand-knees) sacral pressure during UCrsquos
bull Transverse Liebull Associated with pendulous abdomen uterine
massesfibroids congenital abnormalities of uterus hydramnios
bull Attempt External Cephalic Version if unsuccessful obligatory C-section
Malpresentations (cont)bull Breech presentation
Assessment FHT heard high on the abdomen Leopoldrsquos vaginal exam amp USbull Higher risk of anoxia from prolapsed cord traumatic injury to
the after coming head fracture of spine or arm dysfunctional labor
bull Usually delivered by C-section
External Versionbull External cephalic version (37-38 wks) abdominal
manipulation to change fetal presentationbull Contraindications multiple gestation fetal
breech is engaged in pelvis oligohydramnios nonreactive NST nuchal cord vaginal bleeding IUGR ROM
bull Risks immediate cesarean birthbull Nursing actions NPO 8 hrs NST IV line
terbutaline continuous FHR US used to guide manipulations assess for labor fetal distress O- moms need Rhogam following the procedure
MacrosomiaShoulder Dystociabull Wt gt 4500 gms (9-10 lbs)bull Associated with
bull DM Gestational DM Multiparity Postdates obesitybull Risks
bull Shoulder dystocia difficulty delivering the shoulders after head is delivered (obstetrical emergency)
bull Maternal vaginalcervical tears pp hemorrhage rupturebull Fetal compressed cord fractured clavical asphyxia amp neurologic
damage brachial plexus injury (ErbrsquosPalsy)bull SS Turtle signbull Nursing interventions McRoberts maneuvers suprapubic
pressure PP assess for uterine atonyhemorrhage trauma cerebral or neurologic damage to baby
Video youtubecomwatchv=jV6g427UMxYampfeature=related
McRoberts Maneuvers Video
Multiple Gestationbull Monozygotic (identical) twins can have 1 or 2 placentas
chorions or amnions (uarrrisk if all shared)bull Dizygotic (fraternal) twins 2 of everything
bull Dx faster than usual growth of uterus uarrAFP HCG Ultrasound
bull Risks bull Maternal SAB gestational DM HTNpreeclampsiaHELLP
hydramnios PT labor amp deliverybull Fetal Preterm birth twin-to-twin transfusion
Multiple Gestation (cont)bull Management
bull US to determine what type of twinsbull Prevention of PT laborroutine cervical measurements
(US)bull NST surveillance bull Birth depends on maternal amp fetal complications and
fetal position presentationbull Examination of placentabull Close monitoring PP for hemorrhage (atony)
Abruptio Placentaebull Premature separation of placenta from uterine wallbull SS sharp stabbing pain high in fundus heavy
bleeding (may be occult) hard board-like uterus tense painful uterus signs of shock due to blood loss Port-Wine aminotic fluid if ROM
bull Predisposing fx uarrparity adv maternal age short umbilical cord chronic HTN PIH direct trauma vasoconstriction from cocaine or cigarette use
bull Fetal distress on monitor Can progress to DIC
Abruptio Placentae (cont)bull Management
bull Emergency Immediate c-section if birth not imminent
bull Lg gauge IV bull O2 via mask fetal monitoring
maternal VS lateral positioning labs blood transfusion (have 2 units avail)
bull CBC (HampH) Fibrinogen levels platelet count PTPTT fibrin degradation products ( sx of DIC)
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
for pp hemorrhage
bull Table 26-6 pg 746 differential dx abruptioprevia
Low-lying Marginal
Partial Complete
Placenta Previas
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
Diabetes Pulmonary disease Pregnancy-induced hypertension)
bull Chorioamnionitisbull Suspected fetal problems- Intrauterine Growth
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Inductionbull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessmentbull Bishop Score- rating that determines if the cervix
is ready for induction--Pg 765bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole -Inadequate uterine relaxation between contractions lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveriesbull Forceps
bull Indications unable to push arrested descent need a quick delivery breech
bull Associated with maternalfetal birth trauma rectal sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
laborbull Elective
Placenta Factorsbull Placenta previabull Placental abruptionbull Umbilical cord prolapse
Fetal Factorsbull Breech transverse liebull Macrosomiabull Extreme low birth wtbull Fetal distressbull Fetal anomaliesbull Multiple gestation
Cesarean Birth (cont)bull Mortality
morbiditybull 4 x higher than
vaginal birth in US Most risk assoc with emergency c-section
bull Incisionbull Skin vs uterinebull Classical vs low
transverse
bull Maternal Complicationsbull Infectionbull Anesthesia reactionsbull DeepVeinThrombopheb
itisbull Bleedingbull Ureteralbladder injurybull Increase risk for
subsequent pregnancybull Placenta AcretaPrevia
Infertility
Cesarean Birthbull Pre-op CBC w platelets hold clotbull bicitraantacidbull monitor babybull Teaching pre amp post-op anesthesia recovery
breastfeedingbull Psychosocial issues
bull Fearbull Self-imageself-esteem
Post-Op Carebull Assess fundusbleeding vital signs DVTbull Antibiotics bull Pain Duramorph Breakthrough pain
meds Benadryl for itching Zofran for nausea
bull Clear liquids and advance as toleratedbull Assess for GI function Bowel sounds
Passing flatusbull Ambulation Pre-medicate teach splinting
with pillowbull Stool softener
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
multiparity excessive analgesia Afterpains wwwyoutubecomwatchv=EbItF_7KYCcampfeature=related
Fundal Assessment Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina Cervix returns to firm nongravid consistency
by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum Assessment turn pt to side in Simrsquos
position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments Constipation Give stool softeners as
ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis Superficial leg vein disease
ndash Ss tenderness in portion of vein local heat amp redness normal temperature or low-grade fever
ndash Tx local heat elevate limb bed rest analgesia elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation Engorgement day 3 or 4
ndash If breastfeeding Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
Postpartum Complications Postpartum Hemorrhage
ndash CAUSES Uterine atony lacerations retained placental fragments
Risk factorsndash uarr uterine distension multiples polyhydramnios
macrosomia fibroidsndash Trauma rapid or operative birthndash Placental problems previa accreta abruptio
retained placental fragmentsndash Atonic uterus prolonged pitocin magnesium
sulfate or labor uarr maternal age or parity uterine scar chorioamnionitis anemia prior history
ndash Inadequate blood coagulation fetal death or DIC
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
Fetal Attitude
Fetal Lie and Presentation
bull Leopolds maneuversUSbull Longitudinal lie Vertical
bull Presenting part bull cephalic (head)
bull vertex (occiput) chin (mentum) bull breech (buttocks or feet) (c-section)
bull sacrumbull Transverse lie Horizontal
(c-section)bull Presenting part shoulder (acromion)
Fetal position bull momrsquos
pelvis is divided into 4 quadrants RA RP LA LP
bull determine which quadrant presenting part (occiput) is pointing towards
Passengerbull Occiput Anterior (LOA amp ROA) most
common positions amp easiest for birth
bull Occiput Posterior (LOP amp ROP) bull can prolong both 1st amp 2nd stage of laborbull back pain during UCs (back labor)bull Instruct partner in sacral pressure during UCrsquosbull Try ldquoall foursrdquo knee-chest or alternate side-
lying positions to encourage baby to rotate to anterior position
Powersbull Contractions supplied by fundus of uterus
bull Involuntary become stronger as labor progresses
bull Abdominal muscles ldquopushingrdquo by mom (2nd stage)
Psychebull Psychological state amp feelings of mom
bull Coping skillsbull Anxiety fear stressbull Labor support
Onset of laborbull Usually begins between 38 amp 42 weeksbull Mechanism is unknownbull Upper uterus contracts downward pushing
presenting part on cervix causing effacement and dilatation
bull Premonitory signs of laborbull Lightening Braxton-Hicks contractions (false
labor)bull cervical changes (ripening) bull bloody show (mucous plug) bull rupture of membranes (ROM) bull sudden burst of energy
False vs True Labor Contractions
False Labor bull Benign and
irregular contractions
bull Felt first abdominally and remain confined to the abdomen and groin
bull Often disappear with ambulation and sleep
bull Do not increase in duration frequency or intensity
True Laborbull Begin irregularly but
become regular and predictable
bull Felt first in lower back and sweep around to the abdomen in a wave
bull Continue no matter what the womenrsquos level of activity
bull Increase in duration frequency and intensity
False vs True Labor Cervix
False Laborbull No significant
change in dilation or effacement
bull No significant bloody show
bull Fetus- presenting part is not engaged in pelvis
True Laborbull Progressive
change in dilation and effacement
bull Bloody show
bull Presenting part engages in pelvis
Critical Thinkingbull A primigravida client has just arrived in the birthing
unit What steps would be most important for the nurse to perform to gain an understanding of the physical status of the client and her fetus
A Check for ruptured membranes and apply a fetal scalp electrode
B Auscultate the fetal heart rate between and during contractions C Palpate contractions and resting uterine tone D Perform a vaginal exam for cervical dilation and perform
Leopolds maneuvers E Determine gestational age of fetus
Stages of Labor First Stage
bull 0 to 10 cm dilatation--opening of cervix)bull Latent slowest part of the process--slow
dilation mild contractionsbull from onset of regular UCs to rapid
dilatation (about 3-4 cms)bull Active labor ldquopicks up steamrdquo--period of
more rapid dilationbull from 4 cm to full dilatation stronger UCsbull Transition 7-10 cm--intense NV shaking
EffacementThinning of cervix(in )
StationDescent of fetal head(in cm)
Descent offetal head
Station
Floating
Engaged
At outletcrowning
Dilatation amp Effacement
Care of Laboring PatientEarly Labor
bull Initial physical assessment amp history
bull Admission--rapportbull Fetal amp UC
monitoringbull Vaginal exams q 2
hoursbull Vital signsbull Temperature q 4
hours-intact or q 2 hours ROM
bull Educate regarding labor
bull Encourage comfort position changes bladder emptying
bull Assess pain pain tolerance preferred type of labordelivery
bull Reassure regarding what is normal reduce anxiety
Couple excited talkative pain is manageable
Care of Laboring Patient Active Labor
bull Transition (7-10 cm) Yikes ldquoout of controlrdquo shaking nauseavomiting sweating pain is intensebull Prepare for delivery
bull Second stage (Pushing)bull Educateinstruct regarding pushingbull Assess urge to push and fetal descentbull Encouragemotivate patient assess fatiguebull Monitor fetalmaternal response to pushing
bulge crowningbull Signs of imminent birth perineal bulging
Couple quieter discouraged pain increasing
Stages of LaborSecond Stage
bull Pushing amp descent of baby (STATION)bull Full dilatation (10 cm) to birth
bull Important NOT to push until full dilationbull Assessment Urge to push Rectal
pressurebull Push only with UCrsquosbull Crowning babyrsquos head is visible at the
opening of vaginabull Cardinal movements of labor
youtubecomwatchv=Xath6kOf0NEampfeature=related youtubecomwatchv=duPxBXN4qMgampfeature=related
Mechanisms of labor A B Descent C Internal rotation D Extension E External rotation
Head Rotation during Descent
Crowning
In the hospital
Alternative settings
Crowning
Stages of Labor Third Stage
bull Placental stage from birth to delivery of placenta
bull Placental separation from uterine wall (rise of fundus sudden gush of blood lengthening of umbilical cord)
bull Entire lining of uterus shedbull Expulsion of placenta
bull Normal blood loss 300-500 mLbull If placenta does not deliver spontaneously can
be delivered manuallybull Pitocin infusion started immediately post
delivery of placenta
Critical Thinkingbull
A client is admitted to the labor unit with contractions 2 to 3 minutes apart and lasting 60 to 90 seconds The client is apprehensive and vomiting This nurse understands this information to indicate that the client is most likely in what phase of labor
bull A) Active bull B) Transition bull C) Latent bull D) Second
Chapter 23Intrapartal Nursing Assessment
Initial Intrapartum AssessmentPages 608-612
bull Vital signsbull Fetal heart rate pattern fetal distressbull Contraction pattern intensity painbull Membrane status--intact ruptured nitrizine test
amniotic fluid clear meconium foul odorbull Prenatal records history of pregnancy
complications previous pregnancies and deliveries maternal health problems
bull Psychosocialfamilycultural issuesbull Labs CBC dip urine for protein glucose
ketonesbull Vaginal Exam--effacementdilationstation fetal
presentationlie Assesses LABOR PROGRESS
Intrauterine Fetal Resuscitation
bull Stop pitocinbull Reposition to left lateral Trendelenberg if neededbull Oxygen via mask at 8-10 Lminbull Increase IV fluidsbull SQ terbutaline (025 mg) if uterus not relaxingbull Vaginal exam for possible cause prolapse fetal
descent rupture abruptionbull Amnioinfusion for variable decelsbull Notify MDmidwife
Which strip shows signs thatImmediate intervention is needed Why What would you do
A
B
Experiences of Painbull Etiology bull Physiologybull Perception
bull Factors influencingAnxiety Psychological factorsExpectations Cultural factorsSupport Fetal position
Comfort and Pain Relief
bull Support from doula or coachbull Alternative therapies
bullRelaxationmassagebull Focusing and imagerybullBreathingbullHerbal preparationsaromatherapybullHypnosis
Comfort and Pain Reliefbull Pharmacological Measures
bullNarcotic analgesicsbullNubainStadolDemerol (pg 689)
bullRegional nerve blocksbullEpiduralspinal
bull Local anesthetic blocksbullPudendalperineal
Systemic AnalgesiaTable 25-3 pg 690
bull Pre-medication Assessment bull Pain level VS allergies drug dependence
(withdrawal) vaginal examprogress in labor UC pattern fetal heart rate tracing
bull Post-medication Assessmentbull VS esp RR LOC dizziness (bedpan)
sedation FHRbull Reversal agent Naloxone (Narcan)
bull Competes with narcotic for opiate receptors Used in both mom and baby (avoid with narcotic dependence)
Regional Anesthesiabull Injection of local anesthesia to block
specific nerve pathwaysbull Epiduralspinal anesthesia
bullSystemic toxicity cardiovascular collapsebullSide effects Hypotension (preload with IV
fluids) fetal distress on FHR tracing spinal HA
bullContradindications coagulation disorders low platelet count (lt 100) allergy neurologic disease aspirin use
bullNursing care Preload IV fluids (LR) monitor BP HR anesthesia level FHR foley cath maternal positioning
Epidural Anesthesia
Medication for Pain Relief Birthbull Local anesthesia
bull Pudendal nerve block (2nd stage episiotomy repair)bull Local infiltration in perineum (episiotomy repair)
bull General anesthesiabull Regional contraindicatedemergencybull Preparation hip wedge preoxygenation cricoid
pressure for intubationbull Complications fetal depression aspiration of
vomitus (Bicitra)
Local anesthesia for Episiotomy
Childbirth at Risk (Ch 26)
Complications of Labor or Delivery
Critical Thinking The client in active labor is requesting pain relief The
physician orders epidural anesthesia for the client Which of the following parameters should the nurse
be prepared to assess immediately after administration of the epidural
bull A) For headache bull B) For urinary retention bull C) The blood pressure bull D) The maternal pulse rate
Precipitous Labor amp Birthbull Labor in lt 3 hoursbull Risk factors
bull Multiparity oxytocin or amniotomy hx of precipitate labor
bull Risks for injurybull Maternal cervical vaginal amp perineal
lacerations with possible hemorrhage pain anxiety
bull Fetal Birth trauma (intracranial bleed brachial palsy) meconium-stained fluid fetal distress
bull Management close monitoring for cervical changes induction
Postterm Pregnancybull gt 42 weeksbull Maternal risks traumahemorrhage due
to larger baby uarroperative deliveryc-section
bull Fetal risks placental changes that darroxygenation to baby and uarrmortality rate oligohydramnios (uarrcord compression during labor) LGA baby (uarrbirth trauma shoulder dystocia) meconium aspiration
bull Management gt 40 wks NST BPP or modified BPP (NST amp AFI) induction
Malpresentationsbull Occiput-posterior (OP)
bull Prolonged labor back labor (sacral nerve compression) arrested dilatation descent perineal tears
bull Usually vaginal but may need C-Section if baby doesnrsquot rotate
bull Management positioning (side-lying knee-chest or hand-knees) sacral pressure during UCrsquos
bull Transverse Liebull Associated with pendulous abdomen uterine
massesfibroids congenital abnormalities of uterus hydramnios
bull Attempt External Cephalic Version if unsuccessful obligatory C-section
Malpresentations (cont)bull Breech presentation
Assessment FHT heard high on the abdomen Leopoldrsquos vaginal exam amp USbull Higher risk of anoxia from prolapsed cord traumatic injury to
the after coming head fracture of spine or arm dysfunctional labor
bull Usually delivered by C-section
External Versionbull External cephalic version (37-38 wks) abdominal
manipulation to change fetal presentationbull Contraindications multiple gestation fetal
breech is engaged in pelvis oligohydramnios nonreactive NST nuchal cord vaginal bleeding IUGR ROM
bull Risks immediate cesarean birthbull Nursing actions NPO 8 hrs NST IV line
terbutaline continuous FHR US used to guide manipulations assess for labor fetal distress O- moms need Rhogam following the procedure
MacrosomiaShoulder Dystociabull Wt gt 4500 gms (9-10 lbs)bull Associated with
bull DM Gestational DM Multiparity Postdates obesitybull Risks
bull Shoulder dystocia difficulty delivering the shoulders after head is delivered (obstetrical emergency)
bull Maternal vaginalcervical tears pp hemorrhage rupturebull Fetal compressed cord fractured clavical asphyxia amp neurologic
damage brachial plexus injury (ErbrsquosPalsy)bull SS Turtle signbull Nursing interventions McRoberts maneuvers suprapubic
pressure PP assess for uterine atonyhemorrhage trauma cerebral or neurologic damage to baby
Video youtubecomwatchv=jV6g427UMxYampfeature=related
McRoberts Maneuvers Video
Multiple Gestationbull Monozygotic (identical) twins can have 1 or 2 placentas
chorions or amnions (uarrrisk if all shared)bull Dizygotic (fraternal) twins 2 of everything
bull Dx faster than usual growth of uterus uarrAFP HCG Ultrasound
bull Risks bull Maternal SAB gestational DM HTNpreeclampsiaHELLP
hydramnios PT labor amp deliverybull Fetal Preterm birth twin-to-twin transfusion
Multiple Gestation (cont)bull Management
bull US to determine what type of twinsbull Prevention of PT laborroutine cervical measurements
(US)bull NST surveillance bull Birth depends on maternal amp fetal complications and
fetal position presentationbull Examination of placentabull Close monitoring PP for hemorrhage (atony)
Abruptio Placentaebull Premature separation of placenta from uterine wallbull SS sharp stabbing pain high in fundus heavy
bleeding (may be occult) hard board-like uterus tense painful uterus signs of shock due to blood loss Port-Wine aminotic fluid if ROM
bull Predisposing fx uarrparity adv maternal age short umbilical cord chronic HTN PIH direct trauma vasoconstriction from cocaine or cigarette use
bull Fetal distress on monitor Can progress to DIC
Abruptio Placentae (cont)bull Management
bull Emergency Immediate c-section if birth not imminent
bull Lg gauge IV bull O2 via mask fetal monitoring
maternal VS lateral positioning labs blood transfusion (have 2 units avail)
bull CBC (HampH) Fibrinogen levels platelet count PTPTT fibrin degradation products ( sx of DIC)
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
for pp hemorrhage
bull Table 26-6 pg 746 differential dx abruptioprevia
Low-lying Marginal
Partial Complete
Placenta Previas
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
Diabetes Pulmonary disease Pregnancy-induced hypertension)
bull Chorioamnionitisbull Suspected fetal problems- Intrauterine Growth
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Inductionbull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessmentbull Bishop Score- rating that determines if the cervix
is ready for induction--Pg 765bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole -Inadequate uterine relaxation between contractions lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveriesbull Forceps
bull Indications unable to push arrested descent need a quick delivery breech
bull Associated with maternalfetal birth trauma rectal sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
laborbull Elective
Placenta Factorsbull Placenta previabull Placental abruptionbull Umbilical cord prolapse
Fetal Factorsbull Breech transverse liebull Macrosomiabull Extreme low birth wtbull Fetal distressbull Fetal anomaliesbull Multiple gestation
Cesarean Birth (cont)bull Mortality
morbiditybull 4 x higher than
vaginal birth in US Most risk assoc with emergency c-section
bull Incisionbull Skin vs uterinebull Classical vs low
transverse
bull Maternal Complicationsbull Infectionbull Anesthesia reactionsbull DeepVeinThrombopheb
itisbull Bleedingbull Ureteralbladder injurybull Increase risk for
subsequent pregnancybull Placenta AcretaPrevia
Infertility
Cesarean Birthbull Pre-op CBC w platelets hold clotbull bicitraantacidbull monitor babybull Teaching pre amp post-op anesthesia recovery
breastfeedingbull Psychosocial issues
bull Fearbull Self-imageself-esteem
Post-Op Carebull Assess fundusbleeding vital signs DVTbull Antibiotics bull Pain Duramorph Breakthrough pain
meds Benadryl for itching Zofran for nausea
bull Clear liquids and advance as toleratedbull Assess for GI function Bowel sounds
Passing flatusbull Ambulation Pre-medicate teach splinting
with pillowbull Stool softener
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
multiparity excessive analgesia Afterpains wwwyoutubecomwatchv=EbItF_7KYCcampfeature=related
Fundal Assessment Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina Cervix returns to firm nongravid consistency
by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum Assessment turn pt to side in Simrsquos
position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments Constipation Give stool softeners as
ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis Superficial leg vein disease
ndash Ss tenderness in portion of vein local heat amp redness normal temperature or low-grade fever
ndash Tx local heat elevate limb bed rest analgesia elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation Engorgement day 3 or 4
ndash If breastfeeding Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
Postpartum Complications Postpartum Hemorrhage
ndash CAUSES Uterine atony lacerations retained placental fragments
Risk factorsndash uarr uterine distension multiples polyhydramnios
macrosomia fibroidsndash Trauma rapid or operative birthndash Placental problems previa accreta abruptio
retained placental fragmentsndash Atonic uterus prolonged pitocin magnesium
sulfate or labor uarr maternal age or parity uterine scar chorioamnionitis anemia prior history
ndash Inadequate blood coagulation fetal death or DIC
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
Fetal Lie and Presentation
bull Leopolds maneuversUSbull Longitudinal lie Vertical
bull Presenting part bull cephalic (head)
bull vertex (occiput) chin (mentum) bull breech (buttocks or feet) (c-section)
bull sacrumbull Transverse lie Horizontal
(c-section)bull Presenting part shoulder (acromion)
Fetal position bull momrsquos
pelvis is divided into 4 quadrants RA RP LA LP
bull determine which quadrant presenting part (occiput) is pointing towards
Passengerbull Occiput Anterior (LOA amp ROA) most
common positions amp easiest for birth
bull Occiput Posterior (LOP amp ROP) bull can prolong both 1st amp 2nd stage of laborbull back pain during UCs (back labor)bull Instruct partner in sacral pressure during UCrsquosbull Try ldquoall foursrdquo knee-chest or alternate side-
lying positions to encourage baby to rotate to anterior position
Powersbull Contractions supplied by fundus of uterus
bull Involuntary become stronger as labor progresses
bull Abdominal muscles ldquopushingrdquo by mom (2nd stage)
Psychebull Psychological state amp feelings of mom
bull Coping skillsbull Anxiety fear stressbull Labor support
Onset of laborbull Usually begins between 38 amp 42 weeksbull Mechanism is unknownbull Upper uterus contracts downward pushing
presenting part on cervix causing effacement and dilatation
bull Premonitory signs of laborbull Lightening Braxton-Hicks contractions (false
labor)bull cervical changes (ripening) bull bloody show (mucous plug) bull rupture of membranes (ROM) bull sudden burst of energy
False vs True Labor Contractions
False Labor bull Benign and
irregular contractions
bull Felt first abdominally and remain confined to the abdomen and groin
bull Often disappear with ambulation and sleep
bull Do not increase in duration frequency or intensity
True Laborbull Begin irregularly but
become regular and predictable
bull Felt first in lower back and sweep around to the abdomen in a wave
bull Continue no matter what the womenrsquos level of activity
bull Increase in duration frequency and intensity
False vs True Labor Cervix
False Laborbull No significant
change in dilation or effacement
bull No significant bloody show
bull Fetus- presenting part is not engaged in pelvis
True Laborbull Progressive
change in dilation and effacement
bull Bloody show
bull Presenting part engages in pelvis
Critical Thinkingbull A primigravida client has just arrived in the birthing
unit What steps would be most important for the nurse to perform to gain an understanding of the physical status of the client and her fetus
A Check for ruptured membranes and apply a fetal scalp electrode
B Auscultate the fetal heart rate between and during contractions C Palpate contractions and resting uterine tone D Perform a vaginal exam for cervical dilation and perform
Leopolds maneuvers E Determine gestational age of fetus
Stages of Labor First Stage
bull 0 to 10 cm dilatation--opening of cervix)bull Latent slowest part of the process--slow
dilation mild contractionsbull from onset of regular UCs to rapid
dilatation (about 3-4 cms)bull Active labor ldquopicks up steamrdquo--period of
more rapid dilationbull from 4 cm to full dilatation stronger UCsbull Transition 7-10 cm--intense NV shaking
EffacementThinning of cervix(in )
StationDescent of fetal head(in cm)
Descent offetal head
Station
Floating
Engaged
At outletcrowning
Dilatation amp Effacement
Care of Laboring PatientEarly Labor
bull Initial physical assessment amp history
bull Admission--rapportbull Fetal amp UC
monitoringbull Vaginal exams q 2
hoursbull Vital signsbull Temperature q 4
hours-intact or q 2 hours ROM
bull Educate regarding labor
bull Encourage comfort position changes bladder emptying
bull Assess pain pain tolerance preferred type of labordelivery
bull Reassure regarding what is normal reduce anxiety
Couple excited talkative pain is manageable
Care of Laboring Patient Active Labor
bull Transition (7-10 cm) Yikes ldquoout of controlrdquo shaking nauseavomiting sweating pain is intensebull Prepare for delivery
bull Second stage (Pushing)bull Educateinstruct regarding pushingbull Assess urge to push and fetal descentbull Encouragemotivate patient assess fatiguebull Monitor fetalmaternal response to pushing
bulge crowningbull Signs of imminent birth perineal bulging
Couple quieter discouraged pain increasing
Stages of LaborSecond Stage
bull Pushing amp descent of baby (STATION)bull Full dilatation (10 cm) to birth
bull Important NOT to push until full dilationbull Assessment Urge to push Rectal
pressurebull Push only with UCrsquosbull Crowning babyrsquos head is visible at the
opening of vaginabull Cardinal movements of labor
youtubecomwatchv=Xath6kOf0NEampfeature=related youtubecomwatchv=duPxBXN4qMgampfeature=related
Mechanisms of labor A B Descent C Internal rotation D Extension E External rotation
Head Rotation during Descent
Crowning
In the hospital
Alternative settings
Crowning
Stages of Labor Third Stage
bull Placental stage from birth to delivery of placenta
bull Placental separation from uterine wall (rise of fundus sudden gush of blood lengthening of umbilical cord)
bull Entire lining of uterus shedbull Expulsion of placenta
bull Normal blood loss 300-500 mLbull If placenta does not deliver spontaneously can
be delivered manuallybull Pitocin infusion started immediately post
delivery of placenta
Critical Thinkingbull
A client is admitted to the labor unit with contractions 2 to 3 minutes apart and lasting 60 to 90 seconds The client is apprehensive and vomiting This nurse understands this information to indicate that the client is most likely in what phase of labor
bull A) Active bull B) Transition bull C) Latent bull D) Second
Chapter 23Intrapartal Nursing Assessment
Initial Intrapartum AssessmentPages 608-612
bull Vital signsbull Fetal heart rate pattern fetal distressbull Contraction pattern intensity painbull Membrane status--intact ruptured nitrizine test
amniotic fluid clear meconium foul odorbull Prenatal records history of pregnancy
complications previous pregnancies and deliveries maternal health problems
bull Psychosocialfamilycultural issuesbull Labs CBC dip urine for protein glucose
ketonesbull Vaginal Exam--effacementdilationstation fetal
presentationlie Assesses LABOR PROGRESS
Intrauterine Fetal Resuscitation
bull Stop pitocinbull Reposition to left lateral Trendelenberg if neededbull Oxygen via mask at 8-10 Lminbull Increase IV fluidsbull SQ terbutaline (025 mg) if uterus not relaxingbull Vaginal exam for possible cause prolapse fetal
descent rupture abruptionbull Amnioinfusion for variable decelsbull Notify MDmidwife
Which strip shows signs thatImmediate intervention is needed Why What would you do
A
B
Experiences of Painbull Etiology bull Physiologybull Perception
bull Factors influencingAnxiety Psychological factorsExpectations Cultural factorsSupport Fetal position
Comfort and Pain Relief
bull Support from doula or coachbull Alternative therapies
bullRelaxationmassagebull Focusing and imagerybullBreathingbullHerbal preparationsaromatherapybullHypnosis
Comfort and Pain Reliefbull Pharmacological Measures
bullNarcotic analgesicsbullNubainStadolDemerol (pg 689)
bullRegional nerve blocksbullEpiduralspinal
bull Local anesthetic blocksbullPudendalperineal
Systemic AnalgesiaTable 25-3 pg 690
bull Pre-medication Assessment bull Pain level VS allergies drug dependence
(withdrawal) vaginal examprogress in labor UC pattern fetal heart rate tracing
bull Post-medication Assessmentbull VS esp RR LOC dizziness (bedpan)
sedation FHRbull Reversal agent Naloxone (Narcan)
bull Competes with narcotic for opiate receptors Used in both mom and baby (avoid with narcotic dependence)
Regional Anesthesiabull Injection of local anesthesia to block
specific nerve pathwaysbull Epiduralspinal anesthesia
bullSystemic toxicity cardiovascular collapsebullSide effects Hypotension (preload with IV
fluids) fetal distress on FHR tracing spinal HA
bullContradindications coagulation disorders low platelet count (lt 100) allergy neurologic disease aspirin use
bullNursing care Preload IV fluids (LR) monitor BP HR anesthesia level FHR foley cath maternal positioning
Epidural Anesthesia
Medication for Pain Relief Birthbull Local anesthesia
bull Pudendal nerve block (2nd stage episiotomy repair)bull Local infiltration in perineum (episiotomy repair)
bull General anesthesiabull Regional contraindicatedemergencybull Preparation hip wedge preoxygenation cricoid
pressure for intubationbull Complications fetal depression aspiration of
vomitus (Bicitra)
Local anesthesia for Episiotomy
Childbirth at Risk (Ch 26)
Complications of Labor or Delivery
Critical Thinking The client in active labor is requesting pain relief The
physician orders epidural anesthesia for the client Which of the following parameters should the nurse
be prepared to assess immediately after administration of the epidural
bull A) For headache bull B) For urinary retention bull C) The blood pressure bull D) The maternal pulse rate
Precipitous Labor amp Birthbull Labor in lt 3 hoursbull Risk factors
bull Multiparity oxytocin or amniotomy hx of precipitate labor
bull Risks for injurybull Maternal cervical vaginal amp perineal
lacerations with possible hemorrhage pain anxiety
bull Fetal Birth trauma (intracranial bleed brachial palsy) meconium-stained fluid fetal distress
bull Management close monitoring for cervical changes induction
Postterm Pregnancybull gt 42 weeksbull Maternal risks traumahemorrhage due
to larger baby uarroperative deliveryc-section
bull Fetal risks placental changes that darroxygenation to baby and uarrmortality rate oligohydramnios (uarrcord compression during labor) LGA baby (uarrbirth trauma shoulder dystocia) meconium aspiration
bull Management gt 40 wks NST BPP or modified BPP (NST amp AFI) induction
Malpresentationsbull Occiput-posterior (OP)
bull Prolonged labor back labor (sacral nerve compression) arrested dilatation descent perineal tears
bull Usually vaginal but may need C-Section if baby doesnrsquot rotate
bull Management positioning (side-lying knee-chest or hand-knees) sacral pressure during UCrsquos
bull Transverse Liebull Associated with pendulous abdomen uterine
massesfibroids congenital abnormalities of uterus hydramnios
bull Attempt External Cephalic Version if unsuccessful obligatory C-section
Malpresentations (cont)bull Breech presentation
Assessment FHT heard high on the abdomen Leopoldrsquos vaginal exam amp USbull Higher risk of anoxia from prolapsed cord traumatic injury to
the after coming head fracture of spine or arm dysfunctional labor
bull Usually delivered by C-section
External Versionbull External cephalic version (37-38 wks) abdominal
manipulation to change fetal presentationbull Contraindications multiple gestation fetal
breech is engaged in pelvis oligohydramnios nonreactive NST nuchal cord vaginal bleeding IUGR ROM
bull Risks immediate cesarean birthbull Nursing actions NPO 8 hrs NST IV line
terbutaline continuous FHR US used to guide manipulations assess for labor fetal distress O- moms need Rhogam following the procedure
MacrosomiaShoulder Dystociabull Wt gt 4500 gms (9-10 lbs)bull Associated with
bull DM Gestational DM Multiparity Postdates obesitybull Risks
bull Shoulder dystocia difficulty delivering the shoulders after head is delivered (obstetrical emergency)
bull Maternal vaginalcervical tears pp hemorrhage rupturebull Fetal compressed cord fractured clavical asphyxia amp neurologic
damage brachial plexus injury (ErbrsquosPalsy)bull SS Turtle signbull Nursing interventions McRoberts maneuvers suprapubic
pressure PP assess for uterine atonyhemorrhage trauma cerebral or neurologic damage to baby
Video youtubecomwatchv=jV6g427UMxYampfeature=related
McRoberts Maneuvers Video
Multiple Gestationbull Monozygotic (identical) twins can have 1 or 2 placentas
chorions or amnions (uarrrisk if all shared)bull Dizygotic (fraternal) twins 2 of everything
bull Dx faster than usual growth of uterus uarrAFP HCG Ultrasound
bull Risks bull Maternal SAB gestational DM HTNpreeclampsiaHELLP
hydramnios PT labor amp deliverybull Fetal Preterm birth twin-to-twin transfusion
Multiple Gestation (cont)bull Management
bull US to determine what type of twinsbull Prevention of PT laborroutine cervical measurements
(US)bull NST surveillance bull Birth depends on maternal amp fetal complications and
fetal position presentationbull Examination of placentabull Close monitoring PP for hemorrhage (atony)
Abruptio Placentaebull Premature separation of placenta from uterine wallbull SS sharp stabbing pain high in fundus heavy
bleeding (may be occult) hard board-like uterus tense painful uterus signs of shock due to blood loss Port-Wine aminotic fluid if ROM
bull Predisposing fx uarrparity adv maternal age short umbilical cord chronic HTN PIH direct trauma vasoconstriction from cocaine or cigarette use
bull Fetal distress on monitor Can progress to DIC
Abruptio Placentae (cont)bull Management
bull Emergency Immediate c-section if birth not imminent
bull Lg gauge IV bull O2 via mask fetal monitoring
maternal VS lateral positioning labs blood transfusion (have 2 units avail)
bull CBC (HampH) Fibrinogen levels platelet count PTPTT fibrin degradation products ( sx of DIC)
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
for pp hemorrhage
bull Table 26-6 pg 746 differential dx abruptioprevia
Low-lying Marginal
Partial Complete
Placenta Previas
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
Diabetes Pulmonary disease Pregnancy-induced hypertension)
bull Chorioamnionitisbull Suspected fetal problems- Intrauterine Growth
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Inductionbull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessmentbull Bishop Score- rating that determines if the cervix
is ready for induction--Pg 765bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole -Inadequate uterine relaxation between contractions lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveriesbull Forceps
bull Indications unable to push arrested descent need a quick delivery breech
bull Associated with maternalfetal birth trauma rectal sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
laborbull Elective
Placenta Factorsbull Placenta previabull Placental abruptionbull Umbilical cord prolapse
Fetal Factorsbull Breech transverse liebull Macrosomiabull Extreme low birth wtbull Fetal distressbull Fetal anomaliesbull Multiple gestation
Cesarean Birth (cont)bull Mortality
morbiditybull 4 x higher than
vaginal birth in US Most risk assoc with emergency c-section
bull Incisionbull Skin vs uterinebull Classical vs low
transverse
bull Maternal Complicationsbull Infectionbull Anesthesia reactionsbull DeepVeinThrombopheb
itisbull Bleedingbull Ureteralbladder injurybull Increase risk for
subsequent pregnancybull Placenta AcretaPrevia
Infertility
Cesarean Birthbull Pre-op CBC w platelets hold clotbull bicitraantacidbull monitor babybull Teaching pre amp post-op anesthesia recovery
breastfeedingbull Psychosocial issues
bull Fearbull Self-imageself-esteem
Post-Op Carebull Assess fundusbleeding vital signs DVTbull Antibiotics bull Pain Duramorph Breakthrough pain
meds Benadryl for itching Zofran for nausea
bull Clear liquids and advance as toleratedbull Assess for GI function Bowel sounds
Passing flatusbull Ambulation Pre-medicate teach splinting
with pillowbull Stool softener
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
multiparity excessive analgesia Afterpains wwwyoutubecomwatchv=EbItF_7KYCcampfeature=related
Fundal Assessment Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina Cervix returns to firm nongravid consistency
by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum Assessment turn pt to side in Simrsquos
position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments Constipation Give stool softeners as
ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis Superficial leg vein disease
ndash Ss tenderness in portion of vein local heat amp redness normal temperature or low-grade fever
ndash Tx local heat elevate limb bed rest analgesia elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation Engorgement day 3 or 4
ndash If breastfeeding Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
Postpartum Complications Postpartum Hemorrhage
ndash CAUSES Uterine atony lacerations retained placental fragments
Risk factorsndash uarr uterine distension multiples polyhydramnios
macrosomia fibroidsndash Trauma rapid or operative birthndash Placental problems previa accreta abruptio
retained placental fragmentsndash Atonic uterus prolonged pitocin magnesium
sulfate or labor uarr maternal age or parity uterine scar chorioamnionitis anemia prior history
ndash Inadequate blood coagulation fetal death or DIC
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
Fetal position bull momrsquos
pelvis is divided into 4 quadrants RA RP LA LP
bull determine which quadrant presenting part (occiput) is pointing towards
Passengerbull Occiput Anterior (LOA amp ROA) most
common positions amp easiest for birth
bull Occiput Posterior (LOP amp ROP) bull can prolong both 1st amp 2nd stage of laborbull back pain during UCs (back labor)bull Instruct partner in sacral pressure during UCrsquosbull Try ldquoall foursrdquo knee-chest or alternate side-
lying positions to encourage baby to rotate to anterior position
Powersbull Contractions supplied by fundus of uterus
bull Involuntary become stronger as labor progresses
bull Abdominal muscles ldquopushingrdquo by mom (2nd stage)
Psychebull Psychological state amp feelings of mom
bull Coping skillsbull Anxiety fear stressbull Labor support
Onset of laborbull Usually begins between 38 amp 42 weeksbull Mechanism is unknownbull Upper uterus contracts downward pushing
presenting part on cervix causing effacement and dilatation
bull Premonitory signs of laborbull Lightening Braxton-Hicks contractions (false
labor)bull cervical changes (ripening) bull bloody show (mucous plug) bull rupture of membranes (ROM) bull sudden burst of energy
False vs True Labor Contractions
False Labor bull Benign and
irregular contractions
bull Felt first abdominally and remain confined to the abdomen and groin
bull Often disappear with ambulation and sleep
bull Do not increase in duration frequency or intensity
True Laborbull Begin irregularly but
become regular and predictable
bull Felt first in lower back and sweep around to the abdomen in a wave
bull Continue no matter what the womenrsquos level of activity
bull Increase in duration frequency and intensity
False vs True Labor Cervix
False Laborbull No significant
change in dilation or effacement
bull No significant bloody show
bull Fetus- presenting part is not engaged in pelvis
True Laborbull Progressive
change in dilation and effacement
bull Bloody show
bull Presenting part engages in pelvis
Critical Thinkingbull A primigravida client has just arrived in the birthing
unit What steps would be most important for the nurse to perform to gain an understanding of the physical status of the client and her fetus
A Check for ruptured membranes and apply a fetal scalp electrode
B Auscultate the fetal heart rate between and during contractions C Palpate contractions and resting uterine tone D Perform a vaginal exam for cervical dilation and perform
Leopolds maneuvers E Determine gestational age of fetus
Stages of Labor First Stage
bull 0 to 10 cm dilatation--opening of cervix)bull Latent slowest part of the process--slow
dilation mild contractionsbull from onset of regular UCs to rapid
dilatation (about 3-4 cms)bull Active labor ldquopicks up steamrdquo--period of
more rapid dilationbull from 4 cm to full dilatation stronger UCsbull Transition 7-10 cm--intense NV shaking
EffacementThinning of cervix(in )
StationDescent of fetal head(in cm)
Descent offetal head
Station
Floating
Engaged
At outletcrowning
Dilatation amp Effacement
Care of Laboring PatientEarly Labor
bull Initial physical assessment amp history
bull Admission--rapportbull Fetal amp UC
monitoringbull Vaginal exams q 2
hoursbull Vital signsbull Temperature q 4
hours-intact or q 2 hours ROM
bull Educate regarding labor
bull Encourage comfort position changes bladder emptying
bull Assess pain pain tolerance preferred type of labordelivery
bull Reassure regarding what is normal reduce anxiety
Couple excited talkative pain is manageable
Care of Laboring Patient Active Labor
bull Transition (7-10 cm) Yikes ldquoout of controlrdquo shaking nauseavomiting sweating pain is intensebull Prepare for delivery
bull Second stage (Pushing)bull Educateinstruct regarding pushingbull Assess urge to push and fetal descentbull Encouragemotivate patient assess fatiguebull Monitor fetalmaternal response to pushing
bulge crowningbull Signs of imminent birth perineal bulging
Couple quieter discouraged pain increasing
Stages of LaborSecond Stage
bull Pushing amp descent of baby (STATION)bull Full dilatation (10 cm) to birth
bull Important NOT to push until full dilationbull Assessment Urge to push Rectal
pressurebull Push only with UCrsquosbull Crowning babyrsquos head is visible at the
opening of vaginabull Cardinal movements of labor
youtubecomwatchv=Xath6kOf0NEampfeature=related youtubecomwatchv=duPxBXN4qMgampfeature=related
Mechanisms of labor A B Descent C Internal rotation D Extension E External rotation
Head Rotation during Descent
Crowning
In the hospital
Alternative settings
Crowning
Stages of Labor Third Stage
bull Placental stage from birth to delivery of placenta
bull Placental separation from uterine wall (rise of fundus sudden gush of blood lengthening of umbilical cord)
bull Entire lining of uterus shedbull Expulsion of placenta
bull Normal blood loss 300-500 mLbull If placenta does not deliver spontaneously can
be delivered manuallybull Pitocin infusion started immediately post
delivery of placenta
Critical Thinkingbull
A client is admitted to the labor unit with contractions 2 to 3 minutes apart and lasting 60 to 90 seconds The client is apprehensive and vomiting This nurse understands this information to indicate that the client is most likely in what phase of labor
bull A) Active bull B) Transition bull C) Latent bull D) Second
Chapter 23Intrapartal Nursing Assessment
Initial Intrapartum AssessmentPages 608-612
bull Vital signsbull Fetal heart rate pattern fetal distressbull Contraction pattern intensity painbull Membrane status--intact ruptured nitrizine test
amniotic fluid clear meconium foul odorbull Prenatal records history of pregnancy
complications previous pregnancies and deliveries maternal health problems
bull Psychosocialfamilycultural issuesbull Labs CBC dip urine for protein glucose
ketonesbull Vaginal Exam--effacementdilationstation fetal
presentationlie Assesses LABOR PROGRESS
Intrauterine Fetal Resuscitation
bull Stop pitocinbull Reposition to left lateral Trendelenberg if neededbull Oxygen via mask at 8-10 Lminbull Increase IV fluidsbull SQ terbutaline (025 mg) if uterus not relaxingbull Vaginal exam for possible cause prolapse fetal
descent rupture abruptionbull Amnioinfusion for variable decelsbull Notify MDmidwife
Which strip shows signs thatImmediate intervention is needed Why What would you do
A
B
Experiences of Painbull Etiology bull Physiologybull Perception
bull Factors influencingAnxiety Psychological factorsExpectations Cultural factorsSupport Fetal position
Comfort and Pain Relief
bull Support from doula or coachbull Alternative therapies
bullRelaxationmassagebull Focusing and imagerybullBreathingbullHerbal preparationsaromatherapybullHypnosis
Comfort and Pain Reliefbull Pharmacological Measures
bullNarcotic analgesicsbullNubainStadolDemerol (pg 689)
bullRegional nerve blocksbullEpiduralspinal
bull Local anesthetic blocksbullPudendalperineal
Systemic AnalgesiaTable 25-3 pg 690
bull Pre-medication Assessment bull Pain level VS allergies drug dependence
(withdrawal) vaginal examprogress in labor UC pattern fetal heart rate tracing
bull Post-medication Assessmentbull VS esp RR LOC dizziness (bedpan)
sedation FHRbull Reversal agent Naloxone (Narcan)
bull Competes with narcotic for opiate receptors Used in both mom and baby (avoid with narcotic dependence)
Regional Anesthesiabull Injection of local anesthesia to block
specific nerve pathwaysbull Epiduralspinal anesthesia
bullSystemic toxicity cardiovascular collapsebullSide effects Hypotension (preload with IV
fluids) fetal distress on FHR tracing spinal HA
bullContradindications coagulation disorders low platelet count (lt 100) allergy neurologic disease aspirin use
bullNursing care Preload IV fluids (LR) monitor BP HR anesthesia level FHR foley cath maternal positioning
Epidural Anesthesia
Medication for Pain Relief Birthbull Local anesthesia
bull Pudendal nerve block (2nd stage episiotomy repair)bull Local infiltration in perineum (episiotomy repair)
bull General anesthesiabull Regional contraindicatedemergencybull Preparation hip wedge preoxygenation cricoid
pressure for intubationbull Complications fetal depression aspiration of
vomitus (Bicitra)
Local anesthesia for Episiotomy
Childbirth at Risk (Ch 26)
Complications of Labor or Delivery
Critical Thinking The client in active labor is requesting pain relief The
physician orders epidural anesthesia for the client Which of the following parameters should the nurse
be prepared to assess immediately after administration of the epidural
bull A) For headache bull B) For urinary retention bull C) The blood pressure bull D) The maternal pulse rate
Precipitous Labor amp Birthbull Labor in lt 3 hoursbull Risk factors
bull Multiparity oxytocin or amniotomy hx of precipitate labor
bull Risks for injurybull Maternal cervical vaginal amp perineal
lacerations with possible hemorrhage pain anxiety
bull Fetal Birth trauma (intracranial bleed brachial palsy) meconium-stained fluid fetal distress
bull Management close monitoring for cervical changes induction
Postterm Pregnancybull gt 42 weeksbull Maternal risks traumahemorrhage due
to larger baby uarroperative deliveryc-section
bull Fetal risks placental changes that darroxygenation to baby and uarrmortality rate oligohydramnios (uarrcord compression during labor) LGA baby (uarrbirth trauma shoulder dystocia) meconium aspiration
bull Management gt 40 wks NST BPP or modified BPP (NST amp AFI) induction
Malpresentationsbull Occiput-posterior (OP)
bull Prolonged labor back labor (sacral nerve compression) arrested dilatation descent perineal tears
bull Usually vaginal but may need C-Section if baby doesnrsquot rotate
bull Management positioning (side-lying knee-chest or hand-knees) sacral pressure during UCrsquos
bull Transverse Liebull Associated with pendulous abdomen uterine
massesfibroids congenital abnormalities of uterus hydramnios
bull Attempt External Cephalic Version if unsuccessful obligatory C-section
Malpresentations (cont)bull Breech presentation
Assessment FHT heard high on the abdomen Leopoldrsquos vaginal exam amp USbull Higher risk of anoxia from prolapsed cord traumatic injury to
the after coming head fracture of spine or arm dysfunctional labor
bull Usually delivered by C-section
External Versionbull External cephalic version (37-38 wks) abdominal
manipulation to change fetal presentationbull Contraindications multiple gestation fetal
breech is engaged in pelvis oligohydramnios nonreactive NST nuchal cord vaginal bleeding IUGR ROM
bull Risks immediate cesarean birthbull Nursing actions NPO 8 hrs NST IV line
terbutaline continuous FHR US used to guide manipulations assess for labor fetal distress O- moms need Rhogam following the procedure
MacrosomiaShoulder Dystociabull Wt gt 4500 gms (9-10 lbs)bull Associated with
bull DM Gestational DM Multiparity Postdates obesitybull Risks
bull Shoulder dystocia difficulty delivering the shoulders after head is delivered (obstetrical emergency)
bull Maternal vaginalcervical tears pp hemorrhage rupturebull Fetal compressed cord fractured clavical asphyxia amp neurologic
damage brachial plexus injury (ErbrsquosPalsy)bull SS Turtle signbull Nursing interventions McRoberts maneuvers suprapubic
pressure PP assess for uterine atonyhemorrhage trauma cerebral or neurologic damage to baby
Video youtubecomwatchv=jV6g427UMxYampfeature=related
McRoberts Maneuvers Video
Multiple Gestationbull Monozygotic (identical) twins can have 1 or 2 placentas
chorions or amnions (uarrrisk if all shared)bull Dizygotic (fraternal) twins 2 of everything
bull Dx faster than usual growth of uterus uarrAFP HCG Ultrasound
bull Risks bull Maternal SAB gestational DM HTNpreeclampsiaHELLP
hydramnios PT labor amp deliverybull Fetal Preterm birth twin-to-twin transfusion
Multiple Gestation (cont)bull Management
bull US to determine what type of twinsbull Prevention of PT laborroutine cervical measurements
(US)bull NST surveillance bull Birth depends on maternal amp fetal complications and
fetal position presentationbull Examination of placentabull Close monitoring PP for hemorrhage (atony)
Abruptio Placentaebull Premature separation of placenta from uterine wallbull SS sharp stabbing pain high in fundus heavy
bleeding (may be occult) hard board-like uterus tense painful uterus signs of shock due to blood loss Port-Wine aminotic fluid if ROM
bull Predisposing fx uarrparity adv maternal age short umbilical cord chronic HTN PIH direct trauma vasoconstriction from cocaine or cigarette use
bull Fetal distress on monitor Can progress to DIC
Abruptio Placentae (cont)bull Management
bull Emergency Immediate c-section if birth not imminent
bull Lg gauge IV bull O2 via mask fetal monitoring
maternal VS lateral positioning labs blood transfusion (have 2 units avail)
bull CBC (HampH) Fibrinogen levels platelet count PTPTT fibrin degradation products ( sx of DIC)
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
for pp hemorrhage
bull Table 26-6 pg 746 differential dx abruptioprevia
Low-lying Marginal
Partial Complete
Placenta Previas
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
Diabetes Pulmonary disease Pregnancy-induced hypertension)
bull Chorioamnionitisbull Suspected fetal problems- Intrauterine Growth
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Inductionbull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessmentbull Bishop Score- rating that determines if the cervix
is ready for induction--Pg 765bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole -Inadequate uterine relaxation between contractions lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveriesbull Forceps
bull Indications unable to push arrested descent need a quick delivery breech
bull Associated with maternalfetal birth trauma rectal sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
laborbull Elective
Placenta Factorsbull Placenta previabull Placental abruptionbull Umbilical cord prolapse
Fetal Factorsbull Breech transverse liebull Macrosomiabull Extreme low birth wtbull Fetal distressbull Fetal anomaliesbull Multiple gestation
Cesarean Birth (cont)bull Mortality
morbiditybull 4 x higher than
vaginal birth in US Most risk assoc with emergency c-section
bull Incisionbull Skin vs uterinebull Classical vs low
transverse
bull Maternal Complicationsbull Infectionbull Anesthesia reactionsbull DeepVeinThrombopheb
itisbull Bleedingbull Ureteralbladder injurybull Increase risk for
subsequent pregnancybull Placenta AcretaPrevia
Infertility
Cesarean Birthbull Pre-op CBC w platelets hold clotbull bicitraantacidbull monitor babybull Teaching pre amp post-op anesthesia recovery
breastfeedingbull Psychosocial issues
bull Fearbull Self-imageself-esteem
Post-Op Carebull Assess fundusbleeding vital signs DVTbull Antibiotics bull Pain Duramorph Breakthrough pain
meds Benadryl for itching Zofran for nausea
bull Clear liquids and advance as toleratedbull Assess for GI function Bowel sounds
Passing flatusbull Ambulation Pre-medicate teach splinting
with pillowbull Stool softener
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
multiparity excessive analgesia Afterpains wwwyoutubecomwatchv=EbItF_7KYCcampfeature=related
Fundal Assessment Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina Cervix returns to firm nongravid consistency
by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum Assessment turn pt to side in Simrsquos
position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments Constipation Give stool softeners as
ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis Superficial leg vein disease
ndash Ss tenderness in portion of vein local heat amp redness normal temperature or low-grade fever
ndash Tx local heat elevate limb bed rest analgesia elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation Engorgement day 3 or 4
ndash If breastfeeding Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
Postpartum Complications Postpartum Hemorrhage
ndash CAUSES Uterine atony lacerations retained placental fragments
Risk factorsndash uarr uterine distension multiples polyhydramnios
macrosomia fibroidsndash Trauma rapid or operative birthndash Placental problems previa accreta abruptio
retained placental fragmentsndash Atonic uterus prolonged pitocin magnesium
sulfate or labor uarr maternal age or parity uterine scar chorioamnionitis anemia prior history
ndash Inadequate blood coagulation fetal death or DIC
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
Passengerbull Occiput Anterior (LOA amp ROA) most
common positions amp easiest for birth
bull Occiput Posterior (LOP amp ROP) bull can prolong both 1st amp 2nd stage of laborbull back pain during UCs (back labor)bull Instruct partner in sacral pressure during UCrsquosbull Try ldquoall foursrdquo knee-chest or alternate side-
lying positions to encourage baby to rotate to anterior position
Powersbull Contractions supplied by fundus of uterus
bull Involuntary become stronger as labor progresses
bull Abdominal muscles ldquopushingrdquo by mom (2nd stage)
Psychebull Psychological state amp feelings of mom
bull Coping skillsbull Anxiety fear stressbull Labor support
Onset of laborbull Usually begins between 38 amp 42 weeksbull Mechanism is unknownbull Upper uterus contracts downward pushing
presenting part on cervix causing effacement and dilatation
bull Premonitory signs of laborbull Lightening Braxton-Hicks contractions (false
labor)bull cervical changes (ripening) bull bloody show (mucous plug) bull rupture of membranes (ROM) bull sudden burst of energy
False vs True Labor Contractions
False Labor bull Benign and
irregular contractions
bull Felt first abdominally and remain confined to the abdomen and groin
bull Often disappear with ambulation and sleep
bull Do not increase in duration frequency or intensity
True Laborbull Begin irregularly but
become regular and predictable
bull Felt first in lower back and sweep around to the abdomen in a wave
bull Continue no matter what the womenrsquos level of activity
bull Increase in duration frequency and intensity
False vs True Labor Cervix
False Laborbull No significant
change in dilation or effacement
bull No significant bloody show
bull Fetus- presenting part is not engaged in pelvis
True Laborbull Progressive
change in dilation and effacement
bull Bloody show
bull Presenting part engages in pelvis
Critical Thinkingbull A primigravida client has just arrived in the birthing
unit What steps would be most important for the nurse to perform to gain an understanding of the physical status of the client and her fetus
A Check for ruptured membranes and apply a fetal scalp electrode
B Auscultate the fetal heart rate between and during contractions C Palpate contractions and resting uterine tone D Perform a vaginal exam for cervical dilation and perform
Leopolds maneuvers E Determine gestational age of fetus
Stages of Labor First Stage
bull 0 to 10 cm dilatation--opening of cervix)bull Latent slowest part of the process--slow
dilation mild contractionsbull from onset of regular UCs to rapid
dilatation (about 3-4 cms)bull Active labor ldquopicks up steamrdquo--period of
more rapid dilationbull from 4 cm to full dilatation stronger UCsbull Transition 7-10 cm--intense NV shaking
EffacementThinning of cervix(in )
StationDescent of fetal head(in cm)
Descent offetal head
Station
Floating
Engaged
At outletcrowning
Dilatation amp Effacement
Care of Laboring PatientEarly Labor
bull Initial physical assessment amp history
bull Admission--rapportbull Fetal amp UC
monitoringbull Vaginal exams q 2
hoursbull Vital signsbull Temperature q 4
hours-intact or q 2 hours ROM
bull Educate regarding labor
bull Encourage comfort position changes bladder emptying
bull Assess pain pain tolerance preferred type of labordelivery
bull Reassure regarding what is normal reduce anxiety
Couple excited talkative pain is manageable
Care of Laboring Patient Active Labor
bull Transition (7-10 cm) Yikes ldquoout of controlrdquo shaking nauseavomiting sweating pain is intensebull Prepare for delivery
bull Second stage (Pushing)bull Educateinstruct regarding pushingbull Assess urge to push and fetal descentbull Encouragemotivate patient assess fatiguebull Monitor fetalmaternal response to pushing
bulge crowningbull Signs of imminent birth perineal bulging
Couple quieter discouraged pain increasing
Stages of LaborSecond Stage
bull Pushing amp descent of baby (STATION)bull Full dilatation (10 cm) to birth
bull Important NOT to push until full dilationbull Assessment Urge to push Rectal
pressurebull Push only with UCrsquosbull Crowning babyrsquos head is visible at the
opening of vaginabull Cardinal movements of labor
youtubecomwatchv=Xath6kOf0NEampfeature=related youtubecomwatchv=duPxBXN4qMgampfeature=related
Mechanisms of labor A B Descent C Internal rotation D Extension E External rotation
Head Rotation during Descent
Crowning
In the hospital
Alternative settings
Crowning
Stages of Labor Third Stage
bull Placental stage from birth to delivery of placenta
bull Placental separation from uterine wall (rise of fundus sudden gush of blood lengthening of umbilical cord)
bull Entire lining of uterus shedbull Expulsion of placenta
bull Normal blood loss 300-500 mLbull If placenta does not deliver spontaneously can
be delivered manuallybull Pitocin infusion started immediately post
delivery of placenta
Critical Thinkingbull
A client is admitted to the labor unit with contractions 2 to 3 minutes apart and lasting 60 to 90 seconds The client is apprehensive and vomiting This nurse understands this information to indicate that the client is most likely in what phase of labor
bull A) Active bull B) Transition bull C) Latent bull D) Second
Chapter 23Intrapartal Nursing Assessment
Initial Intrapartum AssessmentPages 608-612
bull Vital signsbull Fetal heart rate pattern fetal distressbull Contraction pattern intensity painbull Membrane status--intact ruptured nitrizine test
amniotic fluid clear meconium foul odorbull Prenatal records history of pregnancy
complications previous pregnancies and deliveries maternal health problems
bull Psychosocialfamilycultural issuesbull Labs CBC dip urine for protein glucose
ketonesbull Vaginal Exam--effacementdilationstation fetal
presentationlie Assesses LABOR PROGRESS
Intrauterine Fetal Resuscitation
bull Stop pitocinbull Reposition to left lateral Trendelenberg if neededbull Oxygen via mask at 8-10 Lminbull Increase IV fluidsbull SQ terbutaline (025 mg) if uterus not relaxingbull Vaginal exam for possible cause prolapse fetal
descent rupture abruptionbull Amnioinfusion for variable decelsbull Notify MDmidwife
Which strip shows signs thatImmediate intervention is needed Why What would you do
A
B
Experiences of Painbull Etiology bull Physiologybull Perception
bull Factors influencingAnxiety Psychological factorsExpectations Cultural factorsSupport Fetal position
Comfort and Pain Relief
bull Support from doula or coachbull Alternative therapies
bullRelaxationmassagebull Focusing and imagerybullBreathingbullHerbal preparationsaromatherapybullHypnosis
Comfort and Pain Reliefbull Pharmacological Measures
bullNarcotic analgesicsbullNubainStadolDemerol (pg 689)
bullRegional nerve blocksbullEpiduralspinal
bull Local anesthetic blocksbullPudendalperineal
Systemic AnalgesiaTable 25-3 pg 690
bull Pre-medication Assessment bull Pain level VS allergies drug dependence
(withdrawal) vaginal examprogress in labor UC pattern fetal heart rate tracing
bull Post-medication Assessmentbull VS esp RR LOC dizziness (bedpan)
sedation FHRbull Reversal agent Naloxone (Narcan)
bull Competes with narcotic for opiate receptors Used in both mom and baby (avoid with narcotic dependence)
Regional Anesthesiabull Injection of local anesthesia to block
specific nerve pathwaysbull Epiduralspinal anesthesia
bullSystemic toxicity cardiovascular collapsebullSide effects Hypotension (preload with IV
fluids) fetal distress on FHR tracing spinal HA
bullContradindications coagulation disorders low platelet count (lt 100) allergy neurologic disease aspirin use
bullNursing care Preload IV fluids (LR) monitor BP HR anesthesia level FHR foley cath maternal positioning
Epidural Anesthesia
Medication for Pain Relief Birthbull Local anesthesia
bull Pudendal nerve block (2nd stage episiotomy repair)bull Local infiltration in perineum (episiotomy repair)
bull General anesthesiabull Regional contraindicatedemergencybull Preparation hip wedge preoxygenation cricoid
pressure for intubationbull Complications fetal depression aspiration of
vomitus (Bicitra)
Local anesthesia for Episiotomy
Childbirth at Risk (Ch 26)
Complications of Labor or Delivery
Critical Thinking The client in active labor is requesting pain relief The
physician orders epidural anesthesia for the client Which of the following parameters should the nurse
be prepared to assess immediately after administration of the epidural
bull A) For headache bull B) For urinary retention bull C) The blood pressure bull D) The maternal pulse rate
Precipitous Labor amp Birthbull Labor in lt 3 hoursbull Risk factors
bull Multiparity oxytocin or amniotomy hx of precipitate labor
bull Risks for injurybull Maternal cervical vaginal amp perineal
lacerations with possible hemorrhage pain anxiety
bull Fetal Birth trauma (intracranial bleed brachial palsy) meconium-stained fluid fetal distress
bull Management close monitoring for cervical changes induction
Postterm Pregnancybull gt 42 weeksbull Maternal risks traumahemorrhage due
to larger baby uarroperative deliveryc-section
bull Fetal risks placental changes that darroxygenation to baby and uarrmortality rate oligohydramnios (uarrcord compression during labor) LGA baby (uarrbirth trauma shoulder dystocia) meconium aspiration
bull Management gt 40 wks NST BPP or modified BPP (NST amp AFI) induction
Malpresentationsbull Occiput-posterior (OP)
bull Prolonged labor back labor (sacral nerve compression) arrested dilatation descent perineal tears
bull Usually vaginal but may need C-Section if baby doesnrsquot rotate
bull Management positioning (side-lying knee-chest or hand-knees) sacral pressure during UCrsquos
bull Transverse Liebull Associated with pendulous abdomen uterine
massesfibroids congenital abnormalities of uterus hydramnios
bull Attempt External Cephalic Version if unsuccessful obligatory C-section
Malpresentations (cont)bull Breech presentation
Assessment FHT heard high on the abdomen Leopoldrsquos vaginal exam amp USbull Higher risk of anoxia from prolapsed cord traumatic injury to
the after coming head fracture of spine or arm dysfunctional labor
bull Usually delivered by C-section
External Versionbull External cephalic version (37-38 wks) abdominal
manipulation to change fetal presentationbull Contraindications multiple gestation fetal
breech is engaged in pelvis oligohydramnios nonreactive NST nuchal cord vaginal bleeding IUGR ROM
bull Risks immediate cesarean birthbull Nursing actions NPO 8 hrs NST IV line
terbutaline continuous FHR US used to guide manipulations assess for labor fetal distress O- moms need Rhogam following the procedure
MacrosomiaShoulder Dystociabull Wt gt 4500 gms (9-10 lbs)bull Associated with
bull DM Gestational DM Multiparity Postdates obesitybull Risks
bull Shoulder dystocia difficulty delivering the shoulders after head is delivered (obstetrical emergency)
bull Maternal vaginalcervical tears pp hemorrhage rupturebull Fetal compressed cord fractured clavical asphyxia amp neurologic
damage brachial plexus injury (ErbrsquosPalsy)bull SS Turtle signbull Nursing interventions McRoberts maneuvers suprapubic
pressure PP assess for uterine atonyhemorrhage trauma cerebral or neurologic damage to baby
Video youtubecomwatchv=jV6g427UMxYampfeature=related
McRoberts Maneuvers Video
Multiple Gestationbull Monozygotic (identical) twins can have 1 or 2 placentas
chorions or amnions (uarrrisk if all shared)bull Dizygotic (fraternal) twins 2 of everything
bull Dx faster than usual growth of uterus uarrAFP HCG Ultrasound
bull Risks bull Maternal SAB gestational DM HTNpreeclampsiaHELLP
hydramnios PT labor amp deliverybull Fetal Preterm birth twin-to-twin transfusion
Multiple Gestation (cont)bull Management
bull US to determine what type of twinsbull Prevention of PT laborroutine cervical measurements
(US)bull NST surveillance bull Birth depends on maternal amp fetal complications and
fetal position presentationbull Examination of placentabull Close monitoring PP for hemorrhage (atony)
Abruptio Placentaebull Premature separation of placenta from uterine wallbull SS sharp stabbing pain high in fundus heavy
bleeding (may be occult) hard board-like uterus tense painful uterus signs of shock due to blood loss Port-Wine aminotic fluid if ROM
bull Predisposing fx uarrparity adv maternal age short umbilical cord chronic HTN PIH direct trauma vasoconstriction from cocaine or cigarette use
bull Fetal distress on monitor Can progress to DIC
Abruptio Placentae (cont)bull Management
bull Emergency Immediate c-section if birth not imminent
bull Lg gauge IV bull O2 via mask fetal monitoring
maternal VS lateral positioning labs blood transfusion (have 2 units avail)
bull CBC (HampH) Fibrinogen levels platelet count PTPTT fibrin degradation products ( sx of DIC)
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
for pp hemorrhage
bull Table 26-6 pg 746 differential dx abruptioprevia
Low-lying Marginal
Partial Complete
Placenta Previas
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
Diabetes Pulmonary disease Pregnancy-induced hypertension)
bull Chorioamnionitisbull Suspected fetal problems- Intrauterine Growth
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Inductionbull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessmentbull Bishop Score- rating that determines if the cervix
is ready for induction--Pg 765bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole -Inadequate uterine relaxation between contractions lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveriesbull Forceps
bull Indications unable to push arrested descent need a quick delivery breech
bull Associated with maternalfetal birth trauma rectal sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
laborbull Elective
Placenta Factorsbull Placenta previabull Placental abruptionbull Umbilical cord prolapse
Fetal Factorsbull Breech transverse liebull Macrosomiabull Extreme low birth wtbull Fetal distressbull Fetal anomaliesbull Multiple gestation
Cesarean Birth (cont)bull Mortality
morbiditybull 4 x higher than
vaginal birth in US Most risk assoc with emergency c-section
bull Incisionbull Skin vs uterinebull Classical vs low
transverse
bull Maternal Complicationsbull Infectionbull Anesthesia reactionsbull DeepVeinThrombopheb
itisbull Bleedingbull Ureteralbladder injurybull Increase risk for
subsequent pregnancybull Placenta AcretaPrevia
Infertility
Cesarean Birthbull Pre-op CBC w platelets hold clotbull bicitraantacidbull monitor babybull Teaching pre amp post-op anesthesia recovery
breastfeedingbull Psychosocial issues
bull Fearbull Self-imageself-esteem
Post-Op Carebull Assess fundusbleeding vital signs DVTbull Antibiotics bull Pain Duramorph Breakthrough pain
meds Benadryl for itching Zofran for nausea
bull Clear liquids and advance as toleratedbull Assess for GI function Bowel sounds
Passing flatusbull Ambulation Pre-medicate teach splinting
with pillowbull Stool softener
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
multiparity excessive analgesia Afterpains wwwyoutubecomwatchv=EbItF_7KYCcampfeature=related
Fundal Assessment Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina Cervix returns to firm nongravid consistency
by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum Assessment turn pt to side in Simrsquos
position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments Constipation Give stool softeners as
ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis Superficial leg vein disease
ndash Ss tenderness in portion of vein local heat amp redness normal temperature or low-grade fever
ndash Tx local heat elevate limb bed rest analgesia elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation Engorgement day 3 or 4
ndash If breastfeeding Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
Postpartum Complications Postpartum Hemorrhage
ndash CAUSES Uterine atony lacerations retained placental fragments
Risk factorsndash uarr uterine distension multiples polyhydramnios
macrosomia fibroidsndash Trauma rapid or operative birthndash Placental problems previa accreta abruptio
retained placental fragmentsndash Atonic uterus prolonged pitocin magnesium
sulfate or labor uarr maternal age or parity uterine scar chorioamnionitis anemia prior history
ndash Inadequate blood coagulation fetal death or DIC
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
Powersbull Contractions supplied by fundus of uterus
bull Involuntary become stronger as labor progresses
bull Abdominal muscles ldquopushingrdquo by mom (2nd stage)
Psychebull Psychological state amp feelings of mom
bull Coping skillsbull Anxiety fear stressbull Labor support
Onset of laborbull Usually begins between 38 amp 42 weeksbull Mechanism is unknownbull Upper uterus contracts downward pushing
presenting part on cervix causing effacement and dilatation
bull Premonitory signs of laborbull Lightening Braxton-Hicks contractions (false
labor)bull cervical changes (ripening) bull bloody show (mucous plug) bull rupture of membranes (ROM) bull sudden burst of energy
False vs True Labor Contractions
False Labor bull Benign and
irregular contractions
bull Felt first abdominally and remain confined to the abdomen and groin
bull Often disappear with ambulation and sleep
bull Do not increase in duration frequency or intensity
True Laborbull Begin irregularly but
become regular and predictable
bull Felt first in lower back and sweep around to the abdomen in a wave
bull Continue no matter what the womenrsquos level of activity
bull Increase in duration frequency and intensity
False vs True Labor Cervix
False Laborbull No significant
change in dilation or effacement
bull No significant bloody show
bull Fetus- presenting part is not engaged in pelvis
True Laborbull Progressive
change in dilation and effacement
bull Bloody show
bull Presenting part engages in pelvis
Critical Thinkingbull A primigravida client has just arrived in the birthing
unit What steps would be most important for the nurse to perform to gain an understanding of the physical status of the client and her fetus
A Check for ruptured membranes and apply a fetal scalp electrode
B Auscultate the fetal heart rate between and during contractions C Palpate contractions and resting uterine tone D Perform a vaginal exam for cervical dilation and perform
Leopolds maneuvers E Determine gestational age of fetus
Stages of Labor First Stage
bull 0 to 10 cm dilatation--opening of cervix)bull Latent slowest part of the process--slow
dilation mild contractionsbull from onset of regular UCs to rapid
dilatation (about 3-4 cms)bull Active labor ldquopicks up steamrdquo--period of
more rapid dilationbull from 4 cm to full dilatation stronger UCsbull Transition 7-10 cm--intense NV shaking
EffacementThinning of cervix(in )
StationDescent of fetal head(in cm)
Descent offetal head
Station
Floating
Engaged
At outletcrowning
Dilatation amp Effacement
Care of Laboring PatientEarly Labor
bull Initial physical assessment amp history
bull Admission--rapportbull Fetal amp UC
monitoringbull Vaginal exams q 2
hoursbull Vital signsbull Temperature q 4
hours-intact or q 2 hours ROM
bull Educate regarding labor
bull Encourage comfort position changes bladder emptying
bull Assess pain pain tolerance preferred type of labordelivery
bull Reassure regarding what is normal reduce anxiety
Couple excited talkative pain is manageable
Care of Laboring Patient Active Labor
bull Transition (7-10 cm) Yikes ldquoout of controlrdquo shaking nauseavomiting sweating pain is intensebull Prepare for delivery
bull Second stage (Pushing)bull Educateinstruct regarding pushingbull Assess urge to push and fetal descentbull Encouragemotivate patient assess fatiguebull Monitor fetalmaternal response to pushing
bulge crowningbull Signs of imminent birth perineal bulging
Couple quieter discouraged pain increasing
Stages of LaborSecond Stage
bull Pushing amp descent of baby (STATION)bull Full dilatation (10 cm) to birth
bull Important NOT to push until full dilationbull Assessment Urge to push Rectal
pressurebull Push only with UCrsquosbull Crowning babyrsquos head is visible at the
opening of vaginabull Cardinal movements of labor
youtubecomwatchv=Xath6kOf0NEampfeature=related youtubecomwatchv=duPxBXN4qMgampfeature=related
Mechanisms of labor A B Descent C Internal rotation D Extension E External rotation
Head Rotation during Descent
Crowning
In the hospital
Alternative settings
Crowning
Stages of Labor Third Stage
bull Placental stage from birth to delivery of placenta
bull Placental separation from uterine wall (rise of fundus sudden gush of blood lengthening of umbilical cord)
bull Entire lining of uterus shedbull Expulsion of placenta
bull Normal blood loss 300-500 mLbull If placenta does not deliver spontaneously can
be delivered manuallybull Pitocin infusion started immediately post
delivery of placenta
Critical Thinkingbull
A client is admitted to the labor unit with contractions 2 to 3 minutes apart and lasting 60 to 90 seconds The client is apprehensive and vomiting This nurse understands this information to indicate that the client is most likely in what phase of labor
bull A) Active bull B) Transition bull C) Latent bull D) Second
Chapter 23Intrapartal Nursing Assessment
Initial Intrapartum AssessmentPages 608-612
bull Vital signsbull Fetal heart rate pattern fetal distressbull Contraction pattern intensity painbull Membrane status--intact ruptured nitrizine test
amniotic fluid clear meconium foul odorbull Prenatal records history of pregnancy
complications previous pregnancies and deliveries maternal health problems
bull Psychosocialfamilycultural issuesbull Labs CBC dip urine for protein glucose
ketonesbull Vaginal Exam--effacementdilationstation fetal
presentationlie Assesses LABOR PROGRESS
Intrauterine Fetal Resuscitation
bull Stop pitocinbull Reposition to left lateral Trendelenberg if neededbull Oxygen via mask at 8-10 Lminbull Increase IV fluidsbull SQ terbutaline (025 mg) if uterus not relaxingbull Vaginal exam for possible cause prolapse fetal
descent rupture abruptionbull Amnioinfusion for variable decelsbull Notify MDmidwife
Which strip shows signs thatImmediate intervention is needed Why What would you do
A
B
Experiences of Painbull Etiology bull Physiologybull Perception
bull Factors influencingAnxiety Psychological factorsExpectations Cultural factorsSupport Fetal position
Comfort and Pain Relief
bull Support from doula or coachbull Alternative therapies
bullRelaxationmassagebull Focusing and imagerybullBreathingbullHerbal preparationsaromatherapybullHypnosis
Comfort and Pain Reliefbull Pharmacological Measures
bullNarcotic analgesicsbullNubainStadolDemerol (pg 689)
bullRegional nerve blocksbullEpiduralspinal
bull Local anesthetic blocksbullPudendalperineal
Systemic AnalgesiaTable 25-3 pg 690
bull Pre-medication Assessment bull Pain level VS allergies drug dependence
(withdrawal) vaginal examprogress in labor UC pattern fetal heart rate tracing
bull Post-medication Assessmentbull VS esp RR LOC dizziness (bedpan)
sedation FHRbull Reversal agent Naloxone (Narcan)
bull Competes with narcotic for opiate receptors Used in both mom and baby (avoid with narcotic dependence)
Regional Anesthesiabull Injection of local anesthesia to block
specific nerve pathwaysbull Epiduralspinal anesthesia
bullSystemic toxicity cardiovascular collapsebullSide effects Hypotension (preload with IV
fluids) fetal distress on FHR tracing spinal HA
bullContradindications coagulation disorders low platelet count (lt 100) allergy neurologic disease aspirin use
bullNursing care Preload IV fluids (LR) monitor BP HR anesthesia level FHR foley cath maternal positioning
Epidural Anesthesia
Medication for Pain Relief Birthbull Local anesthesia
bull Pudendal nerve block (2nd stage episiotomy repair)bull Local infiltration in perineum (episiotomy repair)
bull General anesthesiabull Regional contraindicatedemergencybull Preparation hip wedge preoxygenation cricoid
pressure for intubationbull Complications fetal depression aspiration of
vomitus (Bicitra)
Local anesthesia for Episiotomy
Childbirth at Risk (Ch 26)
Complications of Labor or Delivery
Critical Thinking The client in active labor is requesting pain relief The
physician orders epidural anesthesia for the client Which of the following parameters should the nurse
be prepared to assess immediately after administration of the epidural
bull A) For headache bull B) For urinary retention bull C) The blood pressure bull D) The maternal pulse rate
Precipitous Labor amp Birthbull Labor in lt 3 hoursbull Risk factors
bull Multiparity oxytocin or amniotomy hx of precipitate labor
bull Risks for injurybull Maternal cervical vaginal amp perineal
lacerations with possible hemorrhage pain anxiety
bull Fetal Birth trauma (intracranial bleed brachial palsy) meconium-stained fluid fetal distress
bull Management close monitoring for cervical changes induction
Postterm Pregnancybull gt 42 weeksbull Maternal risks traumahemorrhage due
to larger baby uarroperative deliveryc-section
bull Fetal risks placental changes that darroxygenation to baby and uarrmortality rate oligohydramnios (uarrcord compression during labor) LGA baby (uarrbirth trauma shoulder dystocia) meconium aspiration
bull Management gt 40 wks NST BPP or modified BPP (NST amp AFI) induction
Malpresentationsbull Occiput-posterior (OP)
bull Prolonged labor back labor (sacral nerve compression) arrested dilatation descent perineal tears
bull Usually vaginal but may need C-Section if baby doesnrsquot rotate
bull Management positioning (side-lying knee-chest or hand-knees) sacral pressure during UCrsquos
bull Transverse Liebull Associated with pendulous abdomen uterine
massesfibroids congenital abnormalities of uterus hydramnios
bull Attempt External Cephalic Version if unsuccessful obligatory C-section
Malpresentations (cont)bull Breech presentation
Assessment FHT heard high on the abdomen Leopoldrsquos vaginal exam amp USbull Higher risk of anoxia from prolapsed cord traumatic injury to
the after coming head fracture of spine or arm dysfunctional labor
bull Usually delivered by C-section
External Versionbull External cephalic version (37-38 wks) abdominal
manipulation to change fetal presentationbull Contraindications multiple gestation fetal
breech is engaged in pelvis oligohydramnios nonreactive NST nuchal cord vaginal bleeding IUGR ROM
bull Risks immediate cesarean birthbull Nursing actions NPO 8 hrs NST IV line
terbutaline continuous FHR US used to guide manipulations assess for labor fetal distress O- moms need Rhogam following the procedure
MacrosomiaShoulder Dystociabull Wt gt 4500 gms (9-10 lbs)bull Associated with
bull DM Gestational DM Multiparity Postdates obesitybull Risks
bull Shoulder dystocia difficulty delivering the shoulders after head is delivered (obstetrical emergency)
bull Maternal vaginalcervical tears pp hemorrhage rupturebull Fetal compressed cord fractured clavical asphyxia amp neurologic
damage brachial plexus injury (ErbrsquosPalsy)bull SS Turtle signbull Nursing interventions McRoberts maneuvers suprapubic
pressure PP assess for uterine atonyhemorrhage trauma cerebral or neurologic damage to baby
Video youtubecomwatchv=jV6g427UMxYampfeature=related
McRoberts Maneuvers Video
Multiple Gestationbull Monozygotic (identical) twins can have 1 or 2 placentas
chorions or amnions (uarrrisk if all shared)bull Dizygotic (fraternal) twins 2 of everything
bull Dx faster than usual growth of uterus uarrAFP HCG Ultrasound
bull Risks bull Maternal SAB gestational DM HTNpreeclampsiaHELLP
hydramnios PT labor amp deliverybull Fetal Preterm birth twin-to-twin transfusion
Multiple Gestation (cont)bull Management
bull US to determine what type of twinsbull Prevention of PT laborroutine cervical measurements
(US)bull NST surveillance bull Birth depends on maternal amp fetal complications and
fetal position presentationbull Examination of placentabull Close monitoring PP for hemorrhage (atony)
Abruptio Placentaebull Premature separation of placenta from uterine wallbull SS sharp stabbing pain high in fundus heavy
bleeding (may be occult) hard board-like uterus tense painful uterus signs of shock due to blood loss Port-Wine aminotic fluid if ROM
bull Predisposing fx uarrparity adv maternal age short umbilical cord chronic HTN PIH direct trauma vasoconstriction from cocaine or cigarette use
bull Fetal distress on monitor Can progress to DIC
Abruptio Placentae (cont)bull Management
bull Emergency Immediate c-section if birth not imminent
bull Lg gauge IV bull O2 via mask fetal monitoring
maternal VS lateral positioning labs blood transfusion (have 2 units avail)
bull CBC (HampH) Fibrinogen levels platelet count PTPTT fibrin degradation products ( sx of DIC)
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
for pp hemorrhage
bull Table 26-6 pg 746 differential dx abruptioprevia
Low-lying Marginal
Partial Complete
Placenta Previas
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
Diabetes Pulmonary disease Pregnancy-induced hypertension)
bull Chorioamnionitisbull Suspected fetal problems- Intrauterine Growth
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Inductionbull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessmentbull Bishop Score- rating that determines if the cervix
is ready for induction--Pg 765bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole -Inadequate uterine relaxation between contractions lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveriesbull Forceps
bull Indications unable to push arrested descent need a quick delivery breech
bull Associated with maternalfetal birth trauma rectal sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
laborbull Elective
Placenta Factorsbull Placenta previabull Placental abruptionbull Umbilical cord prolapse
Fetal Factorsbull Breech transverse liebull Macrosomiabull Extreme low birth wtbull Fetal distressbull Fetal anomaliesbull Multiple gestation
Cesarean Birth (cont)bull Mortality
morbiditybull 4 x higher than
vaginal birth in US Most risk assoc with emergency c-section
bull Incisionbull Skin vs uterinebull Classical vs low
transverse
bull Maternal Complicationsbull Infectionbull Anesthesia reactionsbull DeepVeinThrombopheb
itisbull Bleedingbull Ureteralbladder injurybull Increase risk for
subsequent pregnancybull Placenta AcretaPrevia
Infertility
Cesarean Birthbull Pre-op CBC w platelets hold clotbull bicitraantacidbull monitor babybull Teaching pre amp post-op anesthesia recovery
breastfeedingbull Psychosocial issues
bull Fearbull Self-imageself-esteem
Post-Op Carebull Assess fundusbleeding vital signs DVTbull Antibiotics bull Pain Duramorph Breakthrough pain
meds Benadryl for itching Zofran for nausea
bull Clear liquids and advance as toleratedbull Assess for GI function Bowel sounds
Passing flatusbull Ambulation Pre-medicate teach splinting
with pillowbull Stool softener
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
multiparity excessive analgesia Afterpains wwwyoutubecomwatchv=EbItF_7KYCcampfeature=related
Fundal Assessment Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina Cervix returns to firm nongravid consistency
by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum Assessment turn pt to side in Simrsquos
position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments Constipation Give stool softeners as
ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis Superficial leg vein disease
ndash Ss tenderness in portion of vein local heat amp redness normal temperature or low-grade fever
ndash Tx local heat elevate limb bed rest analgesia elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation Engorgement day 3 or 4
ndash If breastfeeding Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
Postpartum Complications Postpartum Hemorrhage
ndash CAUSES Uterine atony lacerations retained placental fragments
Risk factorsndash uarr uterine distension multiples polyhydramnios
macrosomia fibroidsndash Trauma rapid or operative birthndash Placental problems previa accreta abruptio
retained placental fragmentsndash Atonic uterus prolonged pitocin magnesium
sulfate or labor uarr maternal age or parity uterine scar chorioamnionitis anemia prior history
ndash Inadequate blood coagulation fetal death or DIC
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
Onset of laborbull Usually begins between 38 amp 42 weeksbull Mechanism is unknownbull Upper uterus contracts downward pushing
presenting part on cervix causing effacement and dilatation
bull Premonitory signs of laborbull Lightening Braxton-Hicks contractions (false
labor)bull cervical changes (ripening) bull bloody show (mucous plug) bull rupture of membranes (ROM) bull sudden burst of energy
False vs True Labor Contractions
False Labor bull Benign and
irregular contractions
bull Felt first abdominally and remain confined to the abdomen and groin
bull Often disappear with ambulation and sleep
bull Do not increase in duration frequency or intensity
True Laborbull Begin irregularly but
become regular and predictable
bull Felt first in lower back and sweep around to the abdomen in a wave
bull Continue no matter what the womenrsquos level of activity
bull Increase in duration frequency and intensity
False vs True Labor Cervix
False Laborbull No significant
change in dilation or effacement
bull No significant bloody show
bull Fetus- presenting part is not engaged in pelvis
True Laborbull Progressive
change in dilation and effacement
bull Bloody show
bull Presenting part engages in pelvis
Critical Thinkingbull A primigravida client has just arrived in the birthing
unit What steps would be most important for the nurse to perform to gain an understanding of the physical status of the client and her fetus
A Check for ruptured membranes and apply a fetal scalp electrode
B Auscultate the fetal heart rate between and during contractions C Palpate contractions and resting uterine tone D Perform a vaginal exam for cervical dilation and perform
Leopolds maneuvers E Determine gestational age of fetus
Stages of Labor First Stage
bull 0 to 10 cm dilatation--opening of cervix)bull Latent slowest part of the process--slow
dilation mild contractionsbull from onset of regular UCs to rapid
dilatation (about 3-4 cms)bull Active labor ldquopicks up steamrdquo--period of
more rapid dilationbull from 4 cm to full dilatation stronger UCsbull Transition 7-10 cm--intense NV shaking
EffacementThinning of cervix(in )
StationDescent of fetal head(in cm)
Descent offetal head
Station
Floating
Engaged
At outletcrowning
Dilatation amp Effacement
Care of Laboring PatientEarly Labor
bull Initial physical assessment amp history
bull Admission--rapportbull Fetal amp UC
monitoringbull Vaginal exams q 2
hoursbull Vital signsbull Temperature q 4
hours-intact or q 2 hours ROM
bull Educate regarding labor
bull Encourage comfort position changes bladder emptying
bull Assess pain pain tolerance preferred type of labordelivery
bull Reassure regarding what is normal reduce anxiety
Couple excited talkative pain is manageable
Care of Laboring Patient Active Labor
bull Transition (7-10 cm) Yikes ldquoout of controlrdquo shaking nauseavomiting sweating pain is intensebull Prepare for delivery
bull Second stage (Pushing)bull Educateinstruct regarding pushingbull Assess urge to push and fetal descentbull Encouragemotivate patient assess fatiguebull Monitor fetalmaternal response to pushing
bulge crowningbull Signs of imminent birth perineal bulging
Couple quieter discouraged pain increasing
Stages of LaborSecond Stage
bull Pushing amp descent of baby (STATION)bull Full dilatation (10 cm) to birth
bull Important NOT to push until full dilationbull Assessment Urge to push Rectal
pressurebull Push only with UCrsquosbull Crowning babyrsquos head is visible at the
opening of vaginabull Cardinal movements of labor
youtubecomwatchv=Xath6kOf0NEampfeature=related youtubecomwatchv=duPxBXN4qMgampfeature=related
Mechanisms of labor A B Descent C Internal rotation D Extension E External rotation
Head Rotation during Descent
Crowning
In the hospital
Alternative settings
Crowning
Stages of Labor Third Stage
bull Placental stage from birth to delivery of placenta
bull Placental separation from uterine wall (rise of fundus sudden gush of blood lengthening of umbilical cord)
bull Entire lining of uterus shedbull Expulsion of placenta
bull Normal blood loss 300-500 mLbull If placenta does not deliver spontaneously can
be delivered manuallybull Pitocin infusion started immediately post
delivery of placenta
Critical Thinkingbull
A client is admitted to the labor unit with contractions 2 to 3 minutes apart and lasting 60 to 90 seconds The client is apprehensive and vomiting This nurse understands this information to indicate that the client is most likely in what phase of labor
bull A) Active bull B) Transition bull C) Latent bull D) Second
Chapter 23Intrapartal Nursing Assessment
Initial Intrapartum AssessmentPages 608-612
bull Vital signsbull Fetal heart rate pattern fetal distressbull Contraction pattern intensity painbull Membrane status--intact ruptured nitrizine test
amniotic fluid clear meconium foul odorbull Prenatal records history of pregnancy
complications previous pregnancies and deliveries maternal health problems
bull Psychosocialfamilycultural issuesbull Labs CBC dip urine for protein glucose
ketonesbull Vaginal Exam--effacementdilationstation fetal
presentationlie Assesses LABOR PROGRESS
Intrauterine Fetal Resuscitation
bull Stop pitocinbull Reposition to left lateral Trendelenberg if neededbull Oxygen via mask at 8-10 Lminbull Increase IV fluidsbull SQ terbutaline (025 mg) if uterus not relaxingbull Vaginal exam for possible cause prolapse fetal
descent rupture abruptionbull Amnioinfusion for variable decelsbull Notify MDmidwife
Which strip shows signs thatImmediate intervention is needed Why What would you do
A
B
Experiences of Painbull Etiology bull Physiologybull Perception
bull Factors influencingAnxiety Psychological factorsExpectations Cultural factorsSupport Fetal position
Comfort and Pain Relief
bull Support from doula or coachbull Alternative therapies
bullRelaxationmassagebull Focusing and imagerybullBreathingbullHerbal preparationsaromatherapybullHypnosis
Comfort and Pain Reliefbull Pharmacological Measures
bullNarcotic analgesicsbullNubainStadolDemerol (pg 689)
bullRegional nerve blocksbullEpiduralspinal
bull Local anesthetic blocksbullPudendalperineal
Systemic AnalgesiaTable 25-3 pg 690
bull Pre-medication Assessment bull Pain level VS allergies drug dependence
(withdrawal) vaginal examprogress in labor UC pattern fetal heart rate tracing
bull Post-medication Assessmentbull VS esp RR LOC dizziness (bedpan)
sedation FHRbull Reversal agent Naloxone (Narcan)
bull Competes with narcotic for opiate receptors Used in both mom and baby (avoid with narcotic dependence)
Regional Anesthesiabull Injection of local anesthesia to block
specific nerve pathwaysbull Epiduralspinal anesthesia
bullSystemic toxicity cardiovascular collapsebullSide effects Hypotension (preload with IV
fluids) fetal distress on FHR tracing spinal HA
bullContradindications coagulation disorders low platelet count (lt 100) allergy neurologic disease aspirin use
bullNursing care Preload IV fluids (LR) monitor BP HR anesthesia level FHR foley cath maternal positioning
Epidural Anesthesia
Medication for Pain Relief Birthbull Local anesthesia
bull Pudendal nerve block (2nd stage episiotomy repair)bull Local infiltration in perineum (episiotomy repair)
bull General anesthesiabull Regional contraindicatedemergencybull Preparation hip wedge preoxygenation cricoid
pressure for intubationbull Complications fetal depression aspiration of
vomitus (Bicitra)
Local anesthesia for Episiotomy
Childbirth at Risk (Ch 26)
Complications of Labor or Delivery
Critical Thinking The client in active labor is requesting pain relief The
physician orders epidural anesthesia for the client Which of the following parameters should the nurse
be prepared to assess immediately after administration of the epidural
bull A) For headache bull B) For urinary retention bull C) The blood pressure bull D) The maternal pulse rate
Precipitous Labor amp Birthbull Labor in lt 3 hoursbull Risk factors
bull Multiparity oxytocin or amniotomy hx of precipitate labor
bull Risks for injurybull Maternal cervical vaginal amp perineal
lacerations with possible hemorrhage pain anxiety
bull Fetal Birth trauma (intracranial bleed brachial palsy) meconium-stained fluid fetal distress
bull Management close monitoring for cervical changes induction
Postterm Pregnancybull gt 42 weeksbull Maternal risks traumahemorrhage due
to larger baby uarroperative deliveryc-section
bull Fetal risks placental changes that darroxygenation to baby and uarrmortality rate oligohydramnios (uarrcord compression during labor) LGA baby (uarrbirth trauma shoulder dystocia) meconium aspiration
bull Management gt 40 wks NST BPP or modified BPP (NST amp AFI) induction
Malpresentationsbull Occiput-posterior (OP)
bull Prolonged labor back labor (sacral nerve compression) arrested dilatation descent perineal tears
bull Usually vaginal but may need C-Section if baby doesnrsquot rotate
bull Management positioning (side-lying knee-chest or hand-knees) sacral pressure during UCrsquos
bull Transverse Liebull Associated with pendulous abdomen uterine
massesfibroids congenital abnormalities of uterus hydramnios
bull Attempt External Cephalic Version if unsuccessful obligatory C-section
Malpresentations (cont)bull Breech presentation
Assessment FHT heard high on the abdomen Leopoldrsquos vaginal exam amp USbull Higher risk of anoxia from prolapsed cord traumatic injury to
the after coming head fracture of spine or arm dysfunctional labor
bull Usually delivered by C-section
External Versionbull External cephalic version (37-38 wks) abdominal
manipulation to change fetal presentationbull Contraindications multiple gestation fetal
breech is engaged in pelvis oligohydramnios nonreactive NST nuchal cord vaginal bleeding IUGR ROM
bull Risks immediate cesarean birthbull Nursing actions NPO 8 hrs NST IV line
terbutaline continuous FHR US used to guide manipulations assess for labor fetal distress O- moms need Rhogam following the procedure
MacrosomiaShoulder Dystociabull Wt gt 4500 gms (9-10 lbs)bull Associated with
bull DM Gestational DM Multiparity Postdates obesitybull Risks
bull Shoulder dystocia difficulty delivering the shoulders after head is delivered (obstetrical emergency)
bull Maternal vaginalcervical tears pp hemorrhage rupturebull Fetal compressed cord fractured clavical asphyxia amp neurologic
damage brachial plexus injury (ErbrsquosPalsy)bull SS Turtle signbull Nursing interventions McRoberts maneuvers suprapubic
pressure PP assess for uterine atonyhemorrhage trauma cerebral or neurologic damage to baby
Video youtubecomwatchv=jV6g427UMxYampfeature=related
McRoberts Maneuvers Video
Multiple Gestationbull Monozygotic (identical) twins can have 1 or 2 placentas
chorions or amnions (uarrrisk if all shared)bull Dizygotic (fraternal) twins 2 of everything
bull Dx faster than usual growth of uterus uarrAFP HCG Ultrasound
bull Risks bull Maternal SAB gestational DM HTNpreeclampsiaHELLP
hydramnios PT labor amp deliverybull Fetal Preterm birth twin-to-twin transfusion
Multiple Gestation (cont)bull Management
bull US to determine what type of twinsbull Prevention of PT laborroutine cervical measurements
(US)bull NST surveillance bull Birth depends on maternal amp fetal complications and
fetal position presentationbull Examination of placentabull Close monitoring PP for hemorrhage (atony)
Abruptio Placentaebull Premature separation of placenta from uterine wallbull SS sharp stabbing pain high in fundus heavy
bleeding (may be occult) hard board-like uterus tense painful uterus signs of shock due to blood loss Port-Wine aminotic fluid if ROM
bull Predisposing fx uarrparity adv maternal age short umbilical cord chronic HTN PIH direct trauma vasoconstriction from cocaine or cigarette use
bull Fetal distress on monitor Can progress to DIC
Abruptio Placentae (cont)bull Management
bull Emergency Immediate c-section if birth not imminent
bull Lg gauge IV bull O2 via mask fetal monitoring
maternal VS lateral positioning labs blood transfusion (have 2 units avail)
bull CBC (HampH) Fibrinogen levels platelet count PTPTT fibrin degradation products ( sx of DIC)
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
for pp hemorrhage
bull Table 26-6 pg 746 differential dx abruptioprevia
Low-lying Marginal
Partial Complete
Placenta Previas
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
Diabetes Pulmonary disease Pregnancy-induced hypertension)
bull Chorioamnionitisbull Suspected fetal problems- Intrauterine Growth
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Inductionbull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessmentbull Bishop Score- rating that determines if the cervix
is ready for induction--Pg 765bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole -Inadequate uterine relaxation between contractions lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveriesbull Forceps
bull Indications unable to push arrested descent need a quick delivery breech
bull Associated with maternalfetal birth trauma rectal sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
laborbull Elective
Placenta Factorsbull Placenta previabull Placental abruptionbull Umbilical cord prolapse
Fetal Factorsbull Breech transverse liebull Macrosomiabull Extreme low birth wtbull Fetal distressbull Fetal anomaliesbull Multiple gestation
Cesarean Birth (cont)bull Mortality
morbiditybull 4 x higher than
vaginal birth in US Most risk assoc with emergency c-section
bull Incisionbull Skin vs uterinebull Classical vs low
transverse
bull Maternal Complicationsbull Infectionbull Anesthesia reactionsbull DeepVeinThrombopheb
itisbull Bleedingbull Ureteralbladder injurybull Increase risk for
subsequent pregnancybull Placenta AcretaPrevia
Infertility
Cesarean Birthbull Pre-op CBC w platelets hold clotbull bicitraantacidbull monitor babybull Teaching pre amp post-op anesthesia recovery
breastfeedingbull Psychosocial issues
bull Fearbull Self-imageself-esteem
Post-Op Carebull Assess fundusbleeding vital signs DVTbull Antibiotics bull Pain Duramorph Breakthrough pain
meds Benadryl for itching Zofran for nausea
bull Clear liquids and advance as toleratedbull Assess for GI function Bowel sounds
Passing flatusbull Ambulation Pre-medicate teach splinting
with pillowbull Stool softener
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
multiparity excessive analgesia Afterpains wwwyoutubecomwatchv=EbItF_7KYCcampfeature=related
Fundal Assessment Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina Cervix returns to firm nongravid consistency
by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum Assessment turn pt to side in Simrsquos
position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments Constipation Give stool softeners as
ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis Superficial leg vein disease
ndash Ss tenderness in portion of vein local heat amp redness normal temperature or low-grade fever
ndash Tx local heat elevate limb bed rest analgesia elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation Engorgement day 3 or 4
ndash If breastfeeding Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
Postpartum Complications Postpartum Hemorrhage
ndash CAUSES Uterine atony lacerations retained placental fragments
Risk factorsndash uarr uterine distension multiples polyhydramnios
macrosomia fibroidsndash Trauma rapid or operative birthndash Placental problems previa accreta abruptio
retained placental fragmentsndash Atonic uterus prolonged pitocin magnesium
sulfate or labor uarr maternal age or parity uterine scar chorioamnionitis anemia prior history
ndash Inadequate blood coagulation fetal death or DIC
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
False vs True Labor Contractions
False Labor bull Benign and
irregular contractions
bull Felt first abdominally and remain confined to the abdomen and groin
bull Often disappear with ambulation and sleep
bull Do not increase in duration frequency or intensity
True Laborbull Begin irregularly but
become regular and predictable
bull Felt first in lower back and sweep around to the abdomen in a wave
bull Continue no matter what the womenrsquos level of activity
bull Increase in duration frequency and intensity
False vs True Labor Cervix
False Laborbull No significant
change in dilation or effacement
bull No significant bloody show
bull Fetus- presenting part is not engaged in pelvis
True Laborbull Progressive
change in dilation and effacement
bull Bloody show
bull Presenting part engages in pelvis
Critical Thinkingbull A primigravida client has just arrived in the birthing
unit What steps would be most important for the nurse to perform to gain an understanding of the physical status of the client and her fetus
A Check for ruptured membranes and apply a fetal scalp electrode
B Auscultate the fetal heart rate between and during contractions C Palpate contractions and resting uterine tone D Perform a vaginal exam for cervical dilation and perform
Leopolds maneuvers E Determine gestational age of fetus
Stages of Labor First Stage
bull 0 to 10 cm dilatation--opening of cervix)bull Latent slowest part of the process--slow
dilation mild contractionsbull from onset of regular UCs to rapid
dilatation (about 3-4 cms)bull Active labor ldquopicks up steamrdquo--period of
more rapid dilationbull from 4 cm to full dilatation stronger UCsbull Transition 7-10 cm--intense NV shaking
EffacementThinning of cervix(in )
StationDescent of fetal head(in cm)
Descent offetal head
Station
Floating
Engaged
At outletcrowning
Dilatation amp Effacement
Care of Laboring PatientEarly Labor
bull Initial physical assessment amp history
bull Admission--rapportbull Fetal amp UC
monitoringbull Vaginal exams q 2
hoursbull Vital signsbull Temperature q 4
hours-intact or q 2 hours ROM
bull Educate regarding labor
bull Encourage comfort position changes bladder emptying
bull Assess pain pain tolerance preferred type of labordelivery
bull Reassure regarding what is normal reduce anxiety
Couple excited talkative pain is manageable
Care of Laboring Patient Active Labor
bull Transition (7-10 cm) Yikes ldquoout of controlrdquo shaking nauseavomiting sweating pain is intensebull Prepare for delivery
bull Second stage (Pushing)bull Educateinstruct regarding pushingbull Assess urge to push and fetal descentbull Encouragemotivate patient assess fatiguebull Monitor fetalmaternal response to pushing
bulge crowningbull Signs of imminent birth perineal bulging
Couple quieter discouraged pain increasing
Stages of LaborSecond Stage
bull Pushing amp descent of baby (STATION)bull Full dilatation (10 cm) to birth
bull Important NOT to push until full dilationbull Assessment Urge to push Rectal
pressurebull Push only with UCrsquosbull Crowning babyrsquos head is visible at the
opening of vaginabull Cardinal movements of labor
youtubecomwatchv=Xath6kOf0NEampfeature=related youtubecomwatchv=duPxBXN4qMgampfeature=related
Mechanisms of labor A B Descent C Internal rotation D Extension E External rotation
Head Rotation during Descent
Crowning
In the hospital
Alternative settings
Crowning
Stages of Labor Third Stage
bull Placental stage from birth to delivery of placenta
bull Placental separation from uterine wall (rise of fundus sudden gush of blood lengthening of umbilical cord)
bull Entire lining of uterus shedbull Expulsion of placenta
bull Normal blood loss 300-500 mLbull If placenta does not deliver spontaneously can
be delivered manuallybull Pitocin infusion started immediately post
delivery of placenta
Critical Thinkingbull
A client is admitted to the labor unit with contractions 2 to 3 minutes apart and lasting 60 to 90 seconds The client is apprehensive and vomiting This nurse understands this information to indicate that the client is most likely in what phase of labor
bull A) Active bull B) Transition bull C) Latent bull D) Second
Chapter 23Intrapartal Nursing Assessment
Initial Intrapartum AssessmentPages 608-612
bull Vital signsbull Fetal heart rate pattern fetal distressbull Contraction pattern intensity painbull Membrane status--intact ruptured nitrizine test
amniotic fluid clear meconium foul odorbull Prenatal records history of pregnancy
complications previous pregnancies and deliveries maternal health problems
bull Psychosocialfamilycultural issuesbull Labs CBC dip urine for protein glucose
ketonesbull Vaginal Exam--effacementdilationstation fetal
presentationlie Assesses LABOR PROGRESS
Intrauterine Fetal Resuscitation
bull Stop pitocinbull Reposition to left lateral Trendelenberg if neededbull Oxygen via mask at 8-10 Lminbull Increase IV fluidsbull SQ terbutaline (025 mg) if uterus not relaxingbull Vaginal exam for possible cause prolapse fetal
descent rupture abruptionbull Amnioinfusion for variable decelsbull Notify MDmidwife
Which strip shows signs thatImmediate intervention is needed Why What would you do
A
B
Experiences of Painbull Etiology bull Physiologybull Perception
bull Factors influencingAnxiety Psychological factorsExpectations Cultural factorsSupport Fetal position
Comfort and Pain Relief
bull Support from doula or coachbull Alternative therapies
bullRelaxationmassagebull Focusing and imagerybullBreathingbullHerbal preparationsaromatherapybullHypnosis
Comfort and Pain Reliefbull Pharmacological Measures
bullNarcotic analgesicsbullNubainStadolDemerol (pg 689)
bullRegional nerve blocksbullEpiduralspinal
bull Local anesthetic blocksbullPudendalperineal
Systemic AnalgesiaTable 25-3 pg 690
bull Pre-medication Assessment bull Pain level VS allergies drug dependence
(withdrawal) vaginal examprogress in labor UC pattern fetal heart rate tracing
bull Post-medication Assessmentbull VS esp RR LOC dizziness (bedpan)
sedation FHRbull Reversal agent Naloxone (Narcan)
bull Competes with narcotic for opiate receptors Used in both mom and baby (avoid with narcotic dependence)
Regional Anesthesiabull Injection of local anesthesia to block
specific nerve pathwaysbull Epiduralspinal anesthesia
bullSystemic toxicity cardiovascular collapsebullSide effects Hypotension (preload with IV
fluids) fetal distress on FHR tracing spinal HA
bullContradindications coagulation disorders low platelet count (lt 100) allergy neurologic disease aspirin use
bullNursing care Preload IV fluids (LR) monitor BP HR anesthesia level FHR foley cath maternal positioning
Epidural Anesthesia
Medication for Pain Relief Birthbull Local anesthesia
bull Pudendal nerve block (2nd stage episiotomy repair)bull Local infiltration in perineum (episiotomy repair)
bull General anesthesiabull Regional contraindicatedemergencybull Preparation hip wedge preoxygenation cricoid
pressure for intubationbull Complications fetal depression aspiration of
vomitus (Bicitra)
Local anesthesia for Episiotomy
Childbirth at Risk (Ch 26)
Complications of Labor or Delivery
Critical Thinking The client in active labor is requesting pain relief The
physician orders epidural anesthesia for the client Which of the following parameters should the nurse
be prepared to assess immediately after administration of the epidural
bull A) For headache bull B) For urinary retention bull C) The blood pressure bull D) The maternal pulse rate
Precipitous Labor amp Birthbull Labor in lt 3 hoursbull Risk factors
bull Multiparity oxytocin or amniotomy hx of precipitate labor
bull Risks for injurybull Maternal cervical vaginal amp perineal
lacerations with possible hemorrhage pain anxiety
bull Fetal Birth trauma (intracranial bleed brachial palsy) meconium-stained fluid fetal distress
bull Management close monitoring for cervical changes induction
Postterm Pregnancybull gt 42 weeksbull Maternal risks traumahemorrhage due
to larger baby uarroperative deliveryc-section
bull Fetal risks placental changes that darroxygenation to baby and uarrmortality rate oligohydramnios (uarrcord compression during labor) LGA baby (uarrbirth trauma shoulder dystocia) meconium aspiration
bull Management gt 40 wks NST BPP or modified BPP (NST amp AFI) induction
Malpresentationsbull Occiput-posterior (OP)
bull Prolonged labor back labor (sacral nerve compression) arrested dilatation descent perineal tears
bull Usually vaginal but may need C-Section if baby doesnrsquot rotate
bull Management positioning (side-lying knee-chest or hand-knees) sacral pressure during UCrsquos
bull Transverse Liebull Associated with pendulous abdomen uterine
massesfibroids congenital abnormalities of uterus hydramnios
bull Attempt External Cephalic Version if unsuccessful obligatory C-section
Malpresentations (cont)bull Breech presentation
Assessment FHT heard high on the abdomen Leopoldrsquos vaginal exam amp USbull Higher risk of anoxia from prolapsed cord traumatic injury to
the after coming head fracture of spine or arm dysfunctional labor
bull Usually delivered by C-section
External Versionbull External cephalic version (37-38 wks) abdominal
manipulation to change fetal presentationbull Contraindications multiple gestation fetal
breech is engaged in pelvis oligohydramnios nonreactive NST nuchal cord vaginal bleeding IUGR ROM
bull Risks immediate cesarean birthbull Nursing actions NPO 8 hrs NST IV line
terbutaline continuous FHR US used to guide manipulations assess for labor fetal distress O- moms need Rhogam following the procedure
MacrosomiaShoulder Dystociabull Wt gt 4500 gms (9-10 lbs)bull Associated with
bull DM Gestational DM Multiparity Postdates obesitybull Risks
bull Shoulder dystocia difficulty delivering the shoulders after head is delivered (obstetrical emergency)
bull Maternal vaginalcervical tears pp hemorrhage rupturebull Fetal compressed cord fractured clavical asphyxia amp neurologic
damage brachial plexus injury (ErbrsquosPalsy)bull SS Turtle signbull Nursing interventions McRoberts maneuvers suprapubic
pressure PP assess for uterine atonyhemorrhage trauma cerebral or neurologic damage to baby
Video youtubecomwatchv=jV6g427UMxYampfeature=related
McRoberts Maneuvers Video
Multiple Gestationbull Monozygotic (identical) twins can have 1 or 2 placentas
chorions or amnions (uarrrisk if all shared)bull Dizygotic (fraternal) twins 2 of everything
bull Dx faster than usual growth of uterus uarrAFP HCG Ultrasound
bull Risks bull Maternal SAB gestational DM HTNpreeclampsiaHELLP
hydramnios PT labor amp deliverybull Fetal Preterm birth twin-to-twin transfusion
Multiple Gestation (cont)bull Management
bull US to determine what type of twinsbull Prevention of PT laborroutine cervical measurements
(US)bull NST surveillance bull Birth depends on maternal amp fetal complications and
fetal position presentationbull Examination of placentabull Close monitoring PP for hemorrhage (atony)
Abruptio Placentaebull Premature separation of placenta from uterine wallbull SS sharp stabbing pain high in fundus heavy
bleeding (may be occult) hard board-like uterus tense painful uterus signs of shock due to blood loss Port-Wine aminotic fluid if ROM
bull Predisposing fx uarrparity adv maternal age short umbilical cord chronic HTN PIH direct trauma vasoconstriction from cocaine or cigarette use
bull Fetal distress on monitor Can progress to DIC
Abruptio Placentae (cont)bull Management
bull Emergency Immediate c-section if birth not imminent
bull Lg gauge IV bull O2 via mask fetal monitoring
maternal VS lateral positioning labs blood transfusion (have 2 units avail)
bull CBC (HampH) Fibrinogen levels platelet count PTPTT fibrin degradation products ( sx of DIC)
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
for pp hemorrhage
bull Table 26-6 pg 746 differential dx abruptioprevia
Low-lying Marginal
Partial Complete
Placenta Previas
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
Diabetes Pulmonary disease Pregnancy-induced hypertension)
bull Chorioamnionitisbull Suspected fetal problems- Intrauterine Growth
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Inductionbull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessmentbull Bishop Score- rating that determines if the cervix
is ready for induction--Pg 765bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole -Inadequate uterine relaxation between contractions lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveriesbull Forceps
bull Indications unable to push arrested descent need a quick delivery breech
bull Associated with maternalfetal birth trauma rectal sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
laborbull Elective
Placenta Factorsbull Placenta previabull Placental abruptionbull Umbilical cord prolapse
Fetal Factorsbull Breech transverse liebull Macrosomiabull Extreme low birth wtbull Fetal distressbull Fetal anomaliesbull Multiple gestation
Cesarean Birth (cont)bull Mortality
morbiditybull 4 x higher than
vaginal birth in US Most risk assoc with emergency c-section
bull Incisionbull Skin vs uterinebull Classical vs low
transverse
bull Maternal Complicationsbull Infectionbull Anesthesia reactionsbull DeepVeinThrombopheb
itisbull Bleedingbull Ureteralbladder injurybull Increase risk for
subsequent pregnancybull Placenta AcretaPrevia
Infertility
Cesarean Birthbull Pre-op CBC w platelets hold clotbull bicitraantacidbull monitor babybull Teaching pre amp post-op anesthesia recovery
breastfeedingbull Psychosocial issues
bull Fearbull Self-imageself-esteem
Post-Op Carebull Assess fundusbleeding vital signs DVTbull Antibiotics bull Pain Duramorph Breakthrough pain
meds Benadryl for itching Zofran for nausea
bull Clear liquids and advance as toleratedbull Assess for GI function Bowel sounds
Passing flatusbull Ambulation Pre-medicate teach splinting
with pillowbull Stool softener
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
multiparity excessive analgesia Afterpains wwwyoutubecomwatchv=EbItF_7KYCcampfeature=related
Fundal Assessment Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina Cervix returns to firm nongravid consistency
by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum Assessment turn pt to side in Simrsquos
position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments Constipation Give stool softeners as
ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis Superficial leg vein disease
ndash Ss tenderness in portion of vein local heat amp redness normal temperature or low-grade fever
ndash Tx local heat elevate limb bed rest analgesia elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation Engorgement day 3 or 4
ndash If breastfeeding Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
Postpartum Complications Postpartum Hemorrhage
ndash CAUSES Uterine atony lacerations retained placental fragments
Risk factorsndash uarr uterine distension multiples polyhydramnios
macrosomia fibroidsndash Trauma rapid or operative birthndash Placental problems previa accreta abruptio
retained placental fragmentsndash Atonic uterus prolonged pitocin magnesium
sulfate or labor uarr maternal age or parity uterine scar chorioamnionitis anemia prior history
ndash Inadequate blood coagulation fetal death or DIC
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
False vs True Labor Cervix
False Laborbull No significant
change in dilation or effacement
bull No significant bloody show
bull Fetus- presenting part is not engaged in pelvis
True Laborbull Progressive
change in dilation and effacement
bull Bloody show
bull Presenting part engages in pelvis
Critical Thinkingbull A primigravida client has just arrived in the birthing
unit What steps would be most important for the nurse to perform to gain an understanding of the physical status of the client and her fetus
A Check for ruptured membranes and apply a fetal scalp electrode
B Auscultate the fetal heart rate between and during contractions C Palpate contractions and resting uterine tone D Perform a vaginal exam for cervical dilation and perform
Leopolds maneuvers E Determine gestational age of fetus
Stages of Labor First Stage
bull 0 to 10 cm dilatation--opening of cervix)bull Latent slowest part of the process--slow
dilation mild contractionsbull from onset of regular UCs to rapid
dilatation (about 3-4 cms)bull Active labor ldquopicks up steamrdquo--period of
more rapid dilationbull from 4 cm to full dilatation stronger UCsbull Transition 7-10 cm--intense NV shaking
EffacementThinning of cervix(in )
StationDescent of fetal head(in cm)
Descent offetal head
Station
Floating
Engaged
At outletcrowning
Dilatation amp Effacement
Care of Laboring PatientEarly Labor
bull Initial physical assessment amp history
bull Admission--rapportbull Fetal amp UC
monitoringbull Vaginal exams q 2
hoursbull Vital signsbull Temperature q 4
hours-intact or q 2 hours ROM
bull Educate regarding labor
bull Encourage comfort position changes bladder emptying
bull Assess pain pain tolerance preferred type of labordelivery
bull Reassure regarding what is normal reduce anxiety
Couple excited talkative pain is manageable
Care of Laboring Patient Active Labor
bull Transition (7-10 cm) Yikes ldquoout of controlrdquo shaking nauseavomiting sweating pain is intensebull Prepare for delivery
bull Second stage (Pushing)bull Educateinstruct regarding pushingbull Assess urge to push and fetal descentbull Encouragemotivate patient assess fatiguebull Monitor fetalmaternal response to pushing
bulge crowningbull Signs of imminent birth perineal bulging
Couple quieter discouraged pain increasing
Stages of LaborSecond Stage
bull Pushing amp descent of baby (STATION)bull Full dilatation (10 cm) to birth
bull Important NOT to push until full dilationbull Assessment Urge to push Rectal
pressurebull Push only with UCrsquosbull Crowning babyrsquos head is visible at the
opening of vaginabull Cardinal movements of labor
youtubecomwatchv=Xath6kOf0NEampfeature=related youtubecomwatchv=duPxBXN4qMgampfeature=related
Mechanisms of labor A B Descent C Internal rotation D Extension E External rotation
Head Rotation during Descent
Crowning
In the hospital
Alternative settings
Crowning
Stages of Labor Third Stage
bull Placental stage from birth to delivery of placenta
bull Placental separation from uterine wall (rise of fundus sudden gush of blood lengthening of umbilical cord)
bull Entire lining of uterus shedbull Expulsion of placenta
bull Normal blood loss 300-500 mLbull If placenta does not deliver spontaneously can
be delivered manuallybull Pitocin infusion started immediately post
delivery of placenta
Critical Thinkingbull
A client is admitted to the labor unit with contractions 2 to 3 minutes apart and lasting 60 to 90 seconds The client is apprehensive and vomiting This nurse understands this information to indicate that the client is most likely in what phase of labor
bull A) Active bull B) Transition bull C) Latent bull D) Second
Chapter 23Intrapartal Nursing Assessment
Initial Intrapartum AssessmentPages 608-612
bull Vital signsbull Fetal heart rate pattern fetal distressbull Contraction pattern intensity painbull Membrane status--intact ruptured nitrizine test
amniotic fluid clear meconium foul odorbull Prenatal records history of pregnancy
complications previous pregnancies and deliveries maternal health problems
bull Psychosocialfamilycultural issuesbull Labs CBC dip urine for protein glucose
ketonesbull Vaginal Exam--effacementdilationstation fetal
presentationlie Assesses LABOR PROGRESS
Intrauterine Fetal Resuscitation
bull Stop pitocinbull Reposition to left lateral Trendelenberg if neededbull Oxygen via mask at 8-10 Lminbull Increase IV fluidsbull SQ terbutaline (025 mg) if uterus not relaxingbull Vaginal exam for possible cause prolapse fetal
descent rupture abruptionbull Amnioinfusion for variable decelsbull Notify MDmidwife
Which strip shows signs thatImmediate intervention is needed Why What would you do
A
B
Experiences of Painbull Etiology bull Physiologybull Perception
bull Factors influencingAnxiety Psychological factorsExpectations Cultural factorsSupport Fetal position
Comfort and Pain Relief
bull Support from doula or coachbull Alternative therapies
bullRelaxationmassagebull Focusing and imagerybullBreathingbullHerbal preparationsaromatherapybullHypnosis
Comfort and Pain Reliefbull Pharmacological Measures
bullNarcotic analgesicsbullNubainStadolDemerol (pg 689)
bullRegional nerve blocksbullEpiduralspinal
bull Local anesthetic blocksbullPudendalperineal
Systemic AnalgesiaTable 25-3 pg 690
bull Pre-medication Assessment bull Pain level VS allergies drug dependence
(withdrawal) vaginal examprogress in labor UC pattern fetal heart rate tracing
bull Post-medication Assessmentbull VS esp RR LOC dizziness (bedpan)
sedation FHRbull Reversal agent Naloxone (Narcan)
bull Competes with narcotic for opiate receptors Used in both mom and baby (avoid with narcotic dependence)
Regional Anesthesiabull Injection of local anesthesia to block
specific nerve pathwaysbull Epiduralspinal anesthesia
bullSystemic toxicity cardiovascular collapsebullSide effects Hypotension (preload with IV
fluids) fetal distress on FHR tracing spinal HA
bullContradindications coagulation disorders low platelet count (lt 100) allergy neurologic disease aspirin use
bullNursing care Preload IV fluids (LR) monitor BP HR anesthesia level FHR foley cath maternal positioning
Epidural Anesthesia
Medication for Pain Relief Birthbull Local anesthesia
bull Pudendal nerve block (2nd stage episiotomy repair)bull Local infiltration in perineum (episiotomy repair)
bull General anesthesiabull Regional contraindicatedemergencybull Preparation hip wedge preoxygenation cricoid
pressure for intubationbull Complications fetal depression aspiration of
vomitus (Bicitra)
Local anesthesia for Episiotomy
Childbirth at Risk (Ch 26)
Complications of Labor or Delivery
Critical Thinking The client in active labor is requesting pain relief The
physician orders epidural anesthesia for the client Which of the following parameters should the nurse
be prepared to assess immediately after administration of the epidural
bull A) For headache bull B) For urinary retention bull C) The blood pressure bull D) The maternal pulse rate
Precipitous Labor amp Birthbull Labor in lt 3 hoursbull Risk factors
bull Multiparity oxytocin or amniotomy hx of precipitate labor
bull Risks for injurybull Maternal cervical vaginal amp perineal
lacerations with possible hemorrhage pain anxiety
bull Fetal Birth trauma (intracranial bleed brachial palsy) meconium-stained fluid fetal distress
bull Management close monitoring for cervical changes induction
Postterm Pregnancybull gt 42 weeksbull Maternal risks traumahemorrhage due
to larger baby uarroperative deliveryc-section
bull Fetal risks placental changes that darroxygenation to baby and uarrmortality rate oligohydramnios (uarrcord compression during labor) LGA baby (uarrbirth trauma shoulder dystocia) meconium aspiration
bull Management gt 40 wks NST BPP or modified BPP (NST amp AFI) induction
Malpresentationsbull Occiput-posterior (OP)
bull Prolonged labor back labor (sacral nerve compression) arrested dilatation descent perineal tears
bull Usually vaginal but may need C-Section if baby doesnrsquot rotate
bull Management positioning (side-lying knee-chest or hand-knees) sacral pressure during UCrsquos
bull Transverse Liebull Associated with pendulous abdomen uterine
massesfibroids congenital abnormalities of uterus hydramnios
bull Attempt External Cephalic Version if unsuccessful obligatory C-section
Malpresentations (cont)bull Breech presentation
Assessment FHT heard high on the abdomen Leopoldrsquos vaginal exam amp USbull Higher risk of anoxia from prolapsed cord traumatic injury to
the after coming head fracture of spine or arm dysfunctional labor
bull Usually delivered by C-section
External Versionbull External cephalic version (37-38 wks) abdominal
manipulation to change fetal presentationbull Contraindications multiple gestation fetal
breech is engaged in pelvis oligohydramnios nonreactive NST nuchal cord vaginal bleeding IUGR ROM
bull Risks immediate cesarean birthbull Nursing actions NPO 8 hrs NST IV line
terbutaline continuous FHR US used to guide manipulations assess for labor fetal distress O- moms need Rhogam following the procedure
MacrosomiaShoulder Dystociabull Wt gt 4500 gms (9-10 lbs)bull Associated with
bull DM Gestational DM Multiparity Postdates obesitybull Risks
bull Shoulder dystocia difficulty delivering the shoulders after head is delivered (obstetrical emergency)
bull Maternal vaginalcervical tears pp hemorrhage rupturebull Fetal compressed cord fractured clavical asphyxia amp neurologic
damage brachial plexus injury (ErbrsquosPalsy)bull SS Turtle signbull Nursing interventions McRoberts maneuvers suprapubic
pressure PP assess for uterine atonyhemorrhage trauma cerebral or neurologic damage to baby
Video youtubecomwatchv=jV6g427UMxYampfeature=related
McRoberts Maneuvers Video
Multiple Gestationbull Monozygotic (identical) twins can have 1 or 2 placentas
chorions or amnions (uarrrisk if all shared)bull Dizygotic (fraternal) twins 2 of everything
bull Dx faster than usual growth of uterus uarrAFP HCG Ultrasound
bull Risks bull Maternal SAB gestational DM HTNpreeclampsiaHELLP
hydramnios PT labor amp deliverybull Fetal Preterm birth twin-to-twin transfusion
Multiple Gestation (cont)bull Management
bull US to determine what type of twinsbull Prevention of PT laborroutine cervical measurements
(US)bull NST surveillance bull Birth depends on maternal amp fetal complications and
fetal position presentationbull Examination of placentabull Close monitoring PP for hemorrhage (atony)
Abruptio Placentaebull Premature separation of placenta from uterine wallbull SS sharp stabbing pain high in fundus heavy
bleeding (may be occult) hard board-like uterus tense painful uterus signs of shock due to blood loss Port-Wine aminotic fluid if ROM
bull Predisposing fx uarrparity adv maternal age short umbilical cord chronic HTN PIH direct trauma vasoconstriction from cocaine or cigarette use
bull Fetal distress on monitor Can progress to DIC
Abruptio Placentae (cont)bull Management
bull Emergency Immediate c-section if birth not imminent
bull Lg gauge IV bull O2 via mask fetal monitoring
maternal VS lateral positioning labs blood transfusion (have 2 units avail)
bull CBC (HampH) Fibrinogen levels platelet count PTPTT fibrin degradation products ( sx of DIC)
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
for pp hemorrhage
bull Table 26-6 pg 746 differential dx abruptioprevia
Low-lying Marginal
Partial Complete
Placenta Previas
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
Diabetes Pulmonary disease Pregnancy-induced hypertension)
bull Chorioamnionitisbull Suspected fetal problems- Intrauterine Growth
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Inductionbull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessmentbull Bishop Score- rating that determines if the cervix
is ready for induction--Pg 765bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole -Inadequate uterine relaxation between contractions lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveriesbull Forceps
bull Indications unable to push arrested descent need a quick delivery breech
bull Associated with maternalfetal birth trauma rectal sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
laborbull Elective
Placenta Factorsbull Placenta previabull Placental abruptionbull Umbilical cord prolapse
Fetal Factorsbull Breech transverse liebull Macrosomiabull Extreme low birth wtbull Fetal distressbull Fetal anomaliesbull Multiple gestation
Cesarean Birth (cont)bull Mortality
morbiditybull 4 x higher than
vaginal birth in US Most risk assoc with emergency c-section
bull Incisionbull Skin vs uterinebull Classical vs low
transverse
bull Maternal Complicationsbull Infectionbull Anesthesia reactionsbull DeepVeinThrombopheb
itisbull Bleedingbull Ureteralbladder injurybull Increase risk for
subsequent pregnancybull Placenta AcretaPrevia
Infertility
Cesarean Birthbull Pre-op CBC w platelets hold clotbull bicitraantacidbull monitor babybull Teaching pre amp post-op anesthesia recovery
breastfeedingbull Psychosocial issues
bull Fearbull Self-imageself-esteem
Post-Op Carebull Assess fundusbleeding vital signs DVTbull Antibiotics bull Pain Duramorph Breakthrough pain
meds Benadryl for itching Zofran for nausea
bull Clear liquids and advance as toleratedbull Assess for GI function Bowel sounds
Passing flatusbull Ambulation Pre-medicate teach splinting
with pillowbull Stool softener
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
multiparity excessive analgesia Afterpains wwwyoutubecomwatchv=EbItF_7KYCcampfeature=related
Fundal Assessment Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina Cervix returns to firm nongravid consistency
by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum Assessment turn pt to side in Simrsquos
position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments Constipation Give stool softeners as
ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis Superficial leg vein disease
ndash Ss tenderness in portion of vein local heat amp redness normal temperature or low-grade fever
ndash Tx local heat elevate limb bed rest analgesia elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation Engorgement day 3 or 4
ndash If breastfeeding Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
Postpartum Complications Postpartum Hemorrhage
ndash CAUSES Uterine atony lacerations retained placental fragments
Risk factorsndash uarr uterine distension multiples polyhydramnios
macrosomia fibroidsndash Trauma rapid or operative birthndash Placental problems previa accreta abruptio
retained placental fragmentsndash Atonic uterus prolonged pitocin magnesium
sulfate or labor uarr maternal age or parity uterine scar chorioamnionitis anemia prior history
ndash Inadequate blood coagulation fetal death or DIC
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
Critical Thinkingbull A primigravida client has just arrived in the birthing
unit What steps would be most important for the nurse to perform to gain an understanding of the physical status of the client and her fetus
A Check for ruptured membranes and apply a fetal scalp electrode
B Auscultate the fetal heart rate between and during contractions C Palpate contractions and resting uterine tone D Perform a vaginal exam for cervical dilation and perform
Leopolds maneuvers E Determine gestational age of fetus
Stages of Labor First Stage
bull 0 to 10 cm dilatation--opening of cervix)bull Latent slowest part of the process--slow
dilation mild contractionsbull from onset of regular UCs to rapid
dilatation (about 3-4 cms)bull Active labor ldquopicks up steamrdquo--period of
more rapid dilationbull from 4 cm to full dilatation stronger UCsbull Transition 7-10 cm--intense NV shaking
EffacementThinning of cervix(in )
StationDescent of fetal head(in cm)
Descent offetal head
Station
Floating
Engaged
At outletcrowning
Dilatation amp Effacement
Care of Laboring PatientEarly Labor
bull Initial physical assessment amp history
bull Admission--rapportbull Fetal amp UC
monitoringbull Vaginal exams q 2
hoursbull Vital signsbull Temperature q 4
hours-intact or q 2 hours ROM
bull Educate regarding labor
bull Encourage comfort position changes bladder emptying
bull Assess pain pain tolerance preferred type of labordelivery
bull Reassure regarding what is normal reduce anxiety
Couple excited talkative pain is manageable
Care of Laboring Patient Active Labor
bull Transition (7-10 cm) Yikes ldquoout of controlrdquo shaking nauseavomiting sweating pain is intensebull Prepare for delivery
bull Second stage (Pushing)bull Educateinstruct regarding pushingbull Assess urge to push and fetal descentbull Encouragemotivate patient assess fatiguebull Monitor fetalmaternal response to pushing
bulge crowningbull Signs of imminent birth perineal bulging
Couple quieter discouraged pain increasing
Stages of LaborSecond Stage
bull Pushing amp descent of baby (STATION)bull Full dilatation (10 cm) to birth
bull Important NOT to push until full dilationbull Assessment Urge to push Rectal
pressurebull Push only with UCrsquosbull Crowning babyrsquos head is visible at the
opening of vaginabull Cardinal movements of labor
youtubecomwatchv=Xath6kOf0NEampfeature=related youtubecomwatchv=duPxBXN4qMgampfeature=related
Mechanisms of labor A B Descent C Internal rotation D Extension E External rotation
Head Rotation during Descent
Crowning
In the hospital
Alternative settings
Crowning
Stages of Labor Third Stage
bull Placental stage from birth to delivery of placenta
bull Placental separation from uterine wall (rise of fundus sudden gush of blood lengthening of umbilical cord)
bull Entire lining of uterus shedbull Expulsion of placenta
bull Normal blood loss 300-500 mLbull If placenta does not deliver spontaneously can
be delivered manuallybull Pitocin infusion started immediately post
delivery of placenta
Critical Thinkingbull
A client is admitted to the labor unit with contractions 2 to 3 minutes apart and lasting 60 to 90 seconds The client is apprehensive and vomiting This nurse understands this information to indicate that the client is most likely in what phase of labor
bull A) Active bull B) Transition bull C) Latent bull D) Second
Chapter 23Intrapartal Nursing Assessment
Initial Intrapartum AssessmentPages 608-612
bull Vital signsbull Fetal heart rate pattern fetal distressbull Contraction pattern intensity painbull Membrane status--intact ruptured nitrizine test
amniotic fluid clear meconium foul odorbull Prenatal records history of pregnancy
complications previous pregnancies and deliveries maternal health problems
bull Psychosocialfamilycultural issuesbull Labs CBC dip urine for protein glucose
ketonesbull Vaginal Exam--effacementdilationstation fetal
presentationlie Assesses LABOR PROGRESS
Intrauterine Fetal Resuscitation
bull Stop pitocinbull Reposition to left lateral Trendelenberg if neededbull Oxygen via mask at 8-10 Lminbull Increase IV fluidsbull SQ terbutaline (025 mg) if uterus not relaxingbull Vaginal exam for possible cause prolapse fetal
descent rupture abruptionbull Amnioinfusion for variable decelsbull Notify MDmidwife
Which strip shows signs thatImmediate intervention is needed Why What would you do
A
B
Experiences of Painbull Etiology bull Physiologybull Perception
bull Factors influencingAnxiety Psychological factorsExpectations Cultural factorsSupport Fetal position
Comfort and Pain Relief
bull Support from doula or coachbull Alternative therapies
bullRelaxationmassagebull Focusing and imagerybullBreathingbullHerbal preparationsaromatherapybullHypnosis
Comfort and Pain Reliefbull Pharmacological Measures
bullNarcotic analgesicsbullNubainStadolDemerol (pg 689)
bullRegional nerve blocksbullEpiduralspinal
bull Local anesthetic blocksbullPudendalperineal
Systemic AnalgesiaTable 25-3 pg 690
bull Pre-medication Assessment bull Pain level VS allergies drug dependence
(withdrawal) vaginal examprogress in labor UC pattern fetal heart rate tracing
bull Post-medication Assessmentbull VS esp RR LOC dizziness (bedpan)
sedation FHRbull Reversal agent Naloxone (Narcan)
bull Competes with narcotic for opiate receptors Used in both mom and baby (avoid with narcotic dependence)
Regional Anesthesiabull Injection of local anesthesia to block
specific nerve pathwaysbull Epiduralspinal anesthesia
bullSystemic toxicity cardiovascular collapsebullSide effects Hypotension (preload with IV
fluids) fetal distress on FHR tracing spinal HA
bullContradindications coagulation disorders low platelet count (lt 100) allergy neurologic disease aspirin use
bullNursing care Preload IV fluids (LR) monitor BP HR anesthesia level FHR foley cath maternal positioning
Epidural Anesthesia
Medication for Pain Relief Birthbull Local anesthesia
bull Pudendal nerve block (2nd stage episiotomy repair)bull Local infiltration in perineum (episiotomy repair)
bull General anesthesiabull Regional contraindicatedemergencybull Preparation hip wedge preoxygenation cricoid
pressure for intubationbull Complications fetal depression aspiration of
vomitus (Bicitra)
Local anesthesia for Episiotomy
Childbirth at Risk (Ch 26)
Complications of Labor or Delivery
Critical Thinking The client in active labor is requesting pain relief The
physician orders epidural anesthesia for the client Which of the following parameters should the nurse
be prepared to assess immediately after administration of the epidural
bull A) For headache bull B) For urinary retention bull C) The blood pressure bull D) The maternal pulse rate
Precipitous Labor amp Birthbull Labor in lt 3 hoursbull Risk factors
bull Multiparity oxytocin or amniotomy hx of precipitate labor
bull Risks for injurybull Maternal cervical vaginal amp perineal
lacerations with possible hemorrhage pain anxiety
bull Fetal Birth trauma (intracranial bleed brachial palsy) meconium-stained fluid fetal distress
bull Management close monitoring for cervical changes induction
Postterm Pregnancybull gt 42 weeksbull Maternal risks traumahemorrhage due
to larger baby uarroperative deliveryc-section
bull Fetal risks placental changes that darroxygenation to baby and uarrmortality rate oligohydramnios (uarrcord compression during labor) LGA baby (uarrbirth trauma shoulder dystocia) meconium aspiration
bull Management gt 40 wks NST BPP or modified BPP (NST amp AFI) induction
Malpresentationsbull Occiput-posterior (OP)
bull Prolonged labor back labor (sacral nerve compression) arrested dilatation descent perineal tears
bull Usually vaginal but may need C-Section if baby doesnrsquot rotate
bull Management positioning (side-lying knee-chest or hand-knees) sacral pressure during UCrsquos
bull Transverse Liebull Associated with pendulous abdomen uterine
massesfibroids congenital abnormalities of uterus hydramnios
bull Attempt External Cephalic Version if unsuccessful obligatory C-section
Malpresentations (cont)bull Breech presentation
Assessment FHT heard high on the abdomen Leopoldrsquos vaginal exam amp USbull Higher risk of anoxia from prolapsed cord traumatic injury to
the after coming head fracture of spine or arm dysfunctional labor
bull Usually delivered by C-section
External Versionbull External cephalic version (37-38 wks) abdominal
manipulation to change fetal presentationbull Contraindications multiple gestation fetal
breech is engaged in pelvis oligohydramnios nonreactive NST nuchal cord vaginal bleeding IUGR ROM
bull Risks immediate cesarean birthbull Nursing actions NPO 8 hrs NST IV line
terbutaline continuous FHR US used to guide manipulations assess for labor fetal distress O- moms need Rhogam following the procedure
MacrosomiaShoulder Dystociabull Wt gt 4500 gms (9-10 lbs)bull Associated with
bull DM Gestational DM Multiparity Postdates obesitybull Risks
bull Shoulder dystocia difficulty delivering the shoulders after head is delivered (obstetrical emergency)
bull Maternal vaginalcervical tears pp hemorrhage rupturebull Fetal compressed cord fractured clavical asphyxia amp neurologic
damage brachial plexus injury (ErbrsquosPalsy)bull SS Turtle signbull Nursing interventions McRoberts maneuvers suprapubic
pressure PP assess for uterine atonyhemorrhage trauma cerebral or neurologic damage to baby
Video youtubecomwatchv=jV6g427UMxYampfeature=related
McRoberts Maneuvers Video
Multiple Gestationbull Monozygotic (identical) twins can have 1 or 2 placentas
chorions or amnions (uarrrisk if all shared)bull Dizygotic (fraternal) twins 2 of everything
bull Dx faster than usual growth of uterus uarrAFP HCG Ultrasound
bull Risks bull Maternal SAB gestational DM HTNpreeclampsiaHELLP
hydramnios PT labor amp deliverybull Fetal Preterm birth twin-to-twin transfusion
Multiple Gestation (cont)bull Management
bull US to determine what type of twinsbull Prevention of PT laborroutine cervical measurements
(US)bull NST surveillance bull Birth depends on maternal amp fetal complications and
fetal position presentationbull Examination of placentabull Close monitoring PP for hemorrhage (atony)
Abruptio Placentaebull Premature separation of placenta from uterine wallbull SS sharp stabbing pain high in fundus heavy
bleeding (may be occult) hard board-like uterus tense painful uterus signs of shock due to blood loss Port-Wine aminotic fluid if ROM
bull Predisposing fx uarrparity adv maternal age short umbilical cord chronic HTN PIH direct trauma vasoconstriction from cocaine or cigarette use
bull Fetal distress on monitor Can progress to DIC
Abruptio Placentae (cont)bull Management
bull Emergency Immediate c-section if birth not imminent
bull Lg gauge IV bull O2 via mask fetal monitoring
maternal VS lateral positioning labs blood transfusion (have 2 units avail)
bull CBC (HampH) Fibrinogen levels platelet count PTPTT fibrin degradation products ( sx of DIC)
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
for pp hemorrhage
bull Table 26-6 pg 746 differential dx abruptioprevia
Low-lying Marginal
Partial Complete
Placenta Previas
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
Diabetes Pulmonary disease Pregnancy-induced hypertension)
bull Chorioamnionitisbull Suspected fetal problems- Intrauterine Growth
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Inductionbull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessmentbull Bishop Score- rating that determines if the cervix
is ready for induction--Pg 765bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole -Inadequate uterine relaxation between contractions lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveriesbull Forceps
bull Indications unable to push arrested descent need a quick delivery breech
bull Associated with maternalfetal birth trauma rectal sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
laborbull Elective
Placenta Factorsbull Placenta previabull Placental abruptionbull Umbilical cord prolapse
Fetal Factorsbull Breech transverse liebull Macrosomiabull Extreme low birth wtbull Fetal distressbull Fetal anomaliesbull Multiple gestation
Cesarean Birth (cont)bull Mortality
morbiditybull 4 x higher than
vaginal birth in US Most risk assoc with emergency c-section
bull Incisionbull Skin vs uterinebull Classical vs low
transverse
bull Maternal Complicationsbull Infectionbull Anesthesia reactionsbull DeepVeinThrombopheb
itisbull Bleedingbull Ureteralbladder injurybull Increase risk for
subsequent pregnancybull Placenta AcretaPrevia
Infertility
Cesarean Birthbull Pre-op CBC w platelets hold clotbull bicitraantacidbull monitor babybull Teaching pre amp post-op anesthesia recovery
breastfeedingbull Psychosocial issues
bull Fearbull Self-imageself-esteem
Post-Op Carebull Assess fundusbleeding vital signs DVTbull Antibiotics bull Pain Duramorph Breakthrough pain
meds Benadryl for itching Zofran for nausea
bull Clear liquids and advance as toleratedbull Assess for GI function Bowel sounds
Passing flatusbull Ambulation Pre-medicate teach splinting
with pillowbull Stool softener
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
multiparity excessive analgesia Afterpains wwwyoutubecomwatchv=EbItF_7KYCcampfeature=related
Fundal Assessment Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina Cervix returns to firm nongravid consistency
by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum Assessment turn pt to side in Simrsquos
position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments Constipation Give stool softeners as
ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis Superficial leg vein disease
ndash Ss tenderness in portion of vein local heat amp redness normal temperature or low-grade fever
ndash Tx local heat elevate limb bed rest analgesia elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation Engorgement day 3 or 4
ndash If breastfeeding Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
Postpartum Complications Postpartum Hemorrhage
ndash CAUSES Uterine atony lacerations retained placental fragments
Risk factorsndash uarr uterine distension multiples polyhydramnios
macrosomia fibroidsndash Trauma rapid or operative birthndash Placental problems previa accreta abruptio
retained placental fragmentsndash Atonic uterus prolonged pitocin magnesium
sulfate or labor uarr maternal age or parity uterine scar chorioamnionitis anemia prior history
ndash Inadequate blood coagulation fetal death or DIC
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
Stages of Labor First Stage
bull 0 to 10 cm dilatation--opening of cervix)bull Latent slowest part of the process--slow
dilation mild contractionsbull from onset of regular UCs to rapid
dilatation (about 3-4 cms)bull Active labor ldquopicks up steamrdquo--period of
more rapid dilationbull from 4 cm to full dilatation stronger UCsbull Transition 7-10 cm--intense NV shaking
EffacementThinning of cervix(in )
StationDescent of fetal head(in cm)
Descent offetal head
Station
Floating
Engaged
At outletcrowning
Dilatation amp Effacement
Care of Laboring PatientEarly Labor
bull Initial physical assessment amp history
bull Admission--rapportbull Fetal amp UC
monitoringbull Vaginal exams q 2
hoursbull Vital signsbull Temperature q 4
hours-intact or q 2 hours ROM
bull Educate regarding labor
bull Encourage comfort position changes bladder emptying
bull Assess pain pain tolerance preferred type of labordelivery
bull Reassure regarding what is normal reduce anxiety
Couple excited talkative pain is manageable
Care of Laboring Patient Active Labor
bull Transition (7-10 cm) Yikes ldquoout of controlrdquo shaking nauseavomiting sweating pain is intensebull Prepare for delivery
bull Second stage (Pushing)bull Educateinstruct regarding pushingbull Assess urge to push and fetal descentbull Encouragemotivate patient assess fatiguebull Monitor fetalmaternal response to pushing
bulge crowningbull Signs of imminent birth perineal bulging
Couple quieter discouraged pain increasing
Stages of LaborSecond Stage
bull Pushing amp descent of baby (STATION)bull Full dilatation (10 cm) to birth
bull Important NOT to push until full dilationbull Assessment Urge to push Rectal
pressurebull Push only with UCrsquosbull Crowning babyrsquos head is visible at the
opening of vaginabull Cardinal movements of labor
youtubecomwatchv=Xath6kOf0NEampfeature=related youtubecomwatchv=duPxBXN4qMgampfeature=related
Mechanisms of labor A B Descent C Internal rotation D Extension E External rotation
Head Rotation during Descent
Crowning
In the hospital
Alternative settings
Crowning
Stages of Labor Third Stage
bull Placental stage from birth to delivery of placenta
bull Placental separation from uterine wall (rise of fundus sudden gush of blood lengthening of umbilical cord)
bull Entire lining of uterus shedbull Expulsion of placenta
bull Normal blood loss 300-500 mLbull If placenta does not deliver spontaneously can
be delivered manuallybull Pitocin infusion started immediately post
delivery of placenta
Critical Thinkingbull
A client is admitted to the labor unit with contractions 2 to 3 minutes apart and lasting 60 to 90 seconds The client is apprehensive and vomiting This nurse understands this information to indicate that the client is most likely in what phase of labor
bull A) Active bull B) Transition bull C) Latent bull D) Second
Chapter 23Intrapartal Nursing Assessment
Initial Intrapartum AssessmentPages 608-612
bull Vital signsbull Fetal heart rate pattern fetal distressbull Contraction pattern intensity painbull Membrane status--intact ruptured nitrizine test
amniotic fluid clear meconium foul odorbull Prenatal records history of pregnancy
complications previous pregnancies and deliveries maternal health problems
bull Psychosocialfamilycultural issuesbull Labs CBC dip urine for protein glucose
ketonesbull Vaginal Exam--effacementdilationstation fetal
presentationlie Assesses LABOR PROGRESS
Intrauterine Fetal Resuscitation
bull Stop pitocinbull Reposition to left lateral Trendelenberg if neededbull Oxygen via mask at 8-10 Lminbull Increase IV fluidsbull SQ terbutaline (025 mg) if uterus not relaxingbull Vaginal exam for possible cause prolapse fetal
descent rupture abruptionbull Amnioinfusion for variable decelsbull Notify MDmidwife
Which strip shows signs thatImmediate intervention is needed Why What would you do
A
B
Experiences of Painbull Etiology bull Physiologybull Perception
bull Factors influencingAnxiety Psychological factorsExpectations Cultural factorsSupport Fetal position
Comfort and Pain Relief
bull Support from doula or coachbull Alternative therapies
bullRelaxationmassagebull Focusing and imagerybullBreathingbullHerbal preparationsaromatherapybullHypnosis
Comfort and Pain Reliefbull Pharmacological Measures
bullNarcotic analgesicsbullNubainStadolDemerol (pg 689)
bullRegional nerve blocksbullEpiduralspinal
bull Local anesthetic blocksbullPudendalperineal
Systemic AnalgesiaTable 25-3 pg 690
bull Pre-medication Assessment bull Pain level VS allergies drug dependence
(withdrawal) vaginal examprogress in labor UC pattern fetal heart rate tracing
bull Post-medication Assessmentbull VS esp RR LOC dizziness (bedpan)
sedation FHRbull Reversal agent Naloxone (Narcan)
bull Competes with narcotic for opiate receptors Used in both mom and baby (avoid with narcotic dependence)
Regional Anesthesiabull Injection of local anesthesia to block
specific nerve pathwaysbull Epiduralspinal anesthesia
bullSystemic toxicity cardiovascular collapsebullSide effects Hypotension (preload with IV
fluids) fetal distress on FHR tracing spinal HA
bullContradindications coagulation disorders low platelet count (lt 100) allergy neurologic disease aspirin use
bullNursing care Preload IV fluids (LR) monitor BP HR anesthesia level FHR foley cath maternal positioning
Epidural Anesthesia
Medication for Pain Relief Birthbull Local anesthesia
bull Pudendal nerve block (2nd stage episiotomy repair)bull Local infiltration in perineum (episiotomy repair)
bull General anesthesiabull Regional contraindicatedemergencybull Preparation hip wedge preoxygenation cricoid
pressure for intubationbull Complications fetal depression aspiration of
vomitus (Bicitra)
Local anesthesia for Episiotomy
Childbirth at Risk (Ch 26)
Complications of Labor or Delivery
Critical Thinking The client in active labor is requesting pain relief The
physician orders epidural anesthesia for the client Which of the following parameters should the nurse
be prepared to assess immediately after administration of the epidural
bull A) For headache bull B) For urinary retention bull C) The blood pressure bull D) The maternal pulse rate
Precipitous Labor amp Birthbull Labor in lt 3 hoursbull Risk factors
bull Multiparity oxytocin or amniotomy hx of precipitate labor
bull Risks for injurybull Maternal cervical vaginal amp perineal
lacerations with possible hemorrhage pain anxiety
bull Fetal Birth trauma (intracranial bleed brachial palsy) meconium-stained fluid fetal distress
bull Management close monitoring for cervical changes induction
Postterm Pregnancybull gt 42 weeksbull Maternal risks traumahemorrhage due
to larger baby uarroperative deliveryc-section
bull Fetal risks placental changes that darroxygenation to baby and uarrmortality rate oligohydramnios (uarrcord compression during labor) LGA baby (uarrbirth trauma shoulder dystocia) meconium aspiration
bull Management gt 40 wks NST BPP or modified BPP (NST amp AFI) induction
Malpresentationsbull Occiput-posterior (OP)
bull Prolonged labor back labor (sacral nerve compression) arrested dilatation descent perineal tears
bull Usually vaginal but may need C-Section if baby doesnrsquot rotate
bull Management positioning (side-lying knee-chest or hand-knees) sacral pressure during UCrsquos
bull Transverse Liebull Associated with pendulous abdomen uterine
massesfibroids congenital abnormalities of uterus hydramnios
bull Attempt External Cephalic Version if unsuccessful obligatory C-section
Malpresentations (cont)bull Breech presentation
Assessment FHT heard high on the abdomen Leopoldrsquos vaginal exam amp USbull Higher risk of anoxia from prolapsed cord traumatic injury to
the after coming head fracture of spine or arm dysfunctional labor
bull Usually delivered by C-section
External Versionbull External cephalic version (37-38 wks) abdominal
manipulation to change fetal presentationbull Contraindications multiple gestation fetal
breech is engaged in pelvis oligohydramnios nonreactive NST nuchal cord vaginal bleeding IUGR ROM
bull Risks immediate cesarean birthbull Nursing actions NPO 8 hrs NST IV line
terbutaline continuous FHR US used to guide manipulations assess for labor fetal distress O- moms need Rhogam following the procedure
MacrosomiaShoulder Dystociabull Wt gt 4500 gms (9-10 lbs)bull Associated with
bull DM Gestational DM Multiparity Postdates obesitybull Risks
bull Shoulder dystocia difficulty delivering the shoulders after head is delivered (obstetrical emergency)
bull Maternal vaginalcervical tears pp hemorrhage rupturebull Fetal compressed cord fractured clavical asphyxia amp neurologic
damage brachial plexus injury (ErbrsquosPalsy)bull SS Turtle signbull Nursing interventions McRoberts maneuvers suprapubic
pressure PP assess for uterine atonyhemorrhage trauma cerebral or neurologic damage to baby
Video youtubecomwatchv=jV6g427UMxYampfeature=related
McRoberts Maneuvers Video
Multiple Gestationbull Monozygotic (identical) twins can have 1 or 2 placentas
chorions or amnions (uarrrisk if all shared)bull Dizygotic (fraternal) twins 2 of everything
bull Dx faster than usual growth of uterus uarrAFP HCG Ultrasound
bull Risks bull Maternal SAB gestational DM HTNpreeclampsiaHELLP
hydramnios PT labor amp deliverybull Fetal Preterm birth twin-to-twin transfusion
Multiple Gestation (cont)bull Management
bull US to determine what type of twinsbull Prevention of PT laborroutine cervical measurements
(US)bull NST surveillance bull Birth depends on maternal amp fetal complications and
fetal position presentationbull Examination of placentabull Close monitoring PP for hemorrhage (atony)
Abruptio Placentaebull Premature separation of placenta from uterine wallbull SS sharp stabbing pain high in fundus heavy
bleeding (may be occult) hard board-like uterus tense painful uterus signs of shock due to blood loss Port-Wine aminotic fluid if ROM
bull Predisposing fx uarrparity adv maternal age short umbilical cord chronic HTN PIH direct trauma vasoconstriction from cocaine or cigarette use
bull Fetal distress on monitor Can progress to DIC
Abruptio Placentae (cont)bull Management
bull Emergency Immediate c-section if birth not imminent
bull Lg gauge IV bull O2 via mask fetal monitoring
maternal VS lateral positioning labs blood transfusion (have 2 units avail)
bull CBC (HampH) Fibrinogen levels platelet count PTPTT fibrin degradation products ( sx of DIC)
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
for pp hemorrhage
bull Table 26-6 pg 746 differential dx abruptioprevia
Low-lying Marginal
Partial Complete
Placenta Previas
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
Diabetes Pulmonary disease Pregnancy-induced hypertension)
bull Chorioamnionitisbull Suspected fetal problems- Intrauterine Growth
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Inductionbull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessmentbull Bishop Score- rating that determines if the cervix
is ready for induction--Pg 765bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole -Inadequate uterine relaxation between contractions lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveriesbull Forceps
bull Indications unable to push arrested descent need a quick delivery breech
bull Associated with maternalfetal birth trauma rectal sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
laborbull Elective
Placenta Factorsbull Placenta previabull Placental abruptionbull Umbilical cord prolapse
Fetal Factorsbull Breech transverse liebull Macrosomiabull Extreme low birth wtbull Fetal distressbull Fetal anomaliesbull Multiple gestation
Cesarean Birth (cont)bull Mortality
morbiditybull 4 x higher than
vaginal birth in US Most risk assoc with emergency c-section
bull Incisionbull Skin vs uterinebull Classical vs low
transverse
bull Maternal Complicationsbull Infectionbull Anesthesia reactionsbull DeepVeinThrombopheb
itisbull Bleedingbull Ureteralbladder injurybull Increase risk for
subsequent pregnancybull Placenta AcretaPrevia
Infertility
Cesarean Birthbull Pre-op CBC w platelets hold clotbull bicitraantacidbull monitor babybull Teaching pre amp post-op anesthesia recovery
breastfeedingbull Psychosocial issues
bull Fearbull Self-imageself-esteem
Post-Op Carebull Assess fundusbleeding vital signs DVTbull Antibiotics bull Pain Duramorph Breakthrough pain
meds Benadryl for itching Zofran for nausea
bull Clear liquids and advance as toleratedbull Assess for GI function Bowel sounds
Passing flatusbull Ambulation Pre-medicate teach splinting
with pillowbull Stool softener
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
multiparity excessive analgesia Afterpains wwwyoutubecomwatchv=EbItF_7KYCcampfeature=related
Fundal Assessment Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina Cervix returns to firm nongravid consistency
by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum Assessment turn pt to side in Simrsquos
position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments Constipation Give stool softeners as
ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis Superficial leg vein disease
ndash Ss tenderness in portion of vein local heat amp redness normal temperature or low-grade fever
ndash Tx local heat elevate limb bed rest analgesia elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation Engorgement day 3 or 4
ndash If breastfeeding Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
Postpartum Complications Postpartum Hemorrhage
ndash CAUSES Uterine atony lacerations retained placental fragments
Risk factorsndash uarr uterine distension multiples polyhydramnios
macrosomia fibroidsndash Trauma rapid or operative birthndash Placental problems previa accreta abruptio
retained placental fragmentsndash Atonic uterus prolonged pitocin magnesium
sulfate or labor uarr maternal age or parity uterine scar chorioamnionitis anemia prior history
ndash Inadequate blood coagulation fetal death or DIC
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
EffacementThinning of cervix(in )
StationDescent of fetal head(in cm)
Descent offetal head
Station
Floating
Engaged
At outletcrowning
Dilatation amp Effacement
Care of Laboring PatientEarly Labor
bull Initial physical assessment amp history
bull Admission--rapportbull Fetal amp UC
monitoringbull Vaginal exams q 2
hoursbull Vital signsbull Temperature q 4
hours-intact or q 2 hours ROM
bull Educate regarding labor
bull Encourage comfort position changes bladder emptying
bull Assess pain pain tolerance preferred type of labordelivery
bull Reassure regarding what is normal reduce anxiety
Couple excited talkative pain is manageable
Care of Laboring Patient Active Labor
bull Transition (7-10 cm) Yikes ldquoout of controlrdquo shaking nauseavomiting sweating pain is intensebull Prepare for delivery
bull Second stage (Pushing)bull Educateinstruct regarding pushingbull Assess urge to push and fetal descentbull Encouragemotivate patient assess fatiguebull Monitor fetalmaternal response to pushing
bulge crowningbull Signs of imminent birth perineal bulging
Couple quieter discouraged pain increasing
Stages of LaborSecond Stage
bull Pushing amp descent of baby (STATION)bull Full dilatation (10 cm) to birth
bull Important NOT to push until full dilationbull Assessment Urge to push Rectal
pressurebull Push only with UCrsquosbull Crowning babyrsquos head is visible at the
opening of vaginabull Cardinal movements of labor
youtubecomwatchv=Xath6kOf0NEampfeature=related youtubecomwatchv=duPxBXN4qMgampfeature=related
Mechanisms of labor A B Descent C Internal rotation D Extension E External rotation
Head Rotation during Descent
Crowning
In the hospital
Alternative settings
Crowning
Stages of Labor Third Stage
bull Placental stage from birth to delivery of placenta
bull Placental separation from uterine wall (rise of fundus sudden gush of blood lengthening of umbilical cord)
bull Entire lining of uterus shedbull Expulsion of placenta
bull Normal blood loss 300-500 mLbull If placenta does not deliver spontaneously can
be delivered manuallybull Pitocin infusion started immediately post
delivery of placenta
Critical Thinkingbull
A client is admitted to the labor unit with contractions 2 to 3 minutes apart and lasting 60 to 90 seconds The client is apprehensive and vomiting This nurse understands this information to indicate that the client is most likely in what phase of labor
bull A) Active bull B) Transition bull C) Latent bull D) Second
Chapter 23Intrapartal Nursing Assessment
Initial Intrapartum AssessmentPages 608-612
bull Vital signsbull Fetal heart rate pattern fetal distressbull Contraction pattern intensity painbull Membrane status--intact ruptured nitrizine test
amniotic fluid clear meconium foul odorbull Prenatal records history of pregnancy
complications previous pregnancies and deliveries maternal health problems
bull Psychosocialfamilycultural issuesbull Labs CBC dip urine for protein glucose
ketonesbull Vaginal Exam--effacementdilationstation fetal
presentationlie Assesses LABOR PROGRESS
Intrauterine Fetal Resuscitation
bull Stop pitocinbull Reposition to left lateral Trendelenberg if neededbull Oxygen via mask at 8-10 Lminbull Increase IV fluidsbull SQ terbutaline (025 mg) if uterus not relaxingbull Vaginal exam for possible cause prolapse fetal
descent rupture abruptionbull Amnioinfusion for variable decelsbull Notify MDmidwife
Which strip shows signs thatImmediate intervention is needed Why What would you do
A
B
Experiences of Painbull Etiology bull Physiologybull Perception
bull Factors influencingAnxiety Psychological factorsExpectations Cultural factorsSupport Fetal position
Comfort and Pain Relief
bull Support from doula or coachbull Alternative therapies
bullRelaxationmassagebull Focusing and imagerybullBreathingbullHerbal preparationsaromatherapybullHypnosis
Comfort and Pain Reliefbull Pharmacological Measures
bullNarcotic analgesicsbullNubainStadolDemerol (pg 689)
bullRegional nerve blocksbullEpiduralspinal
bull Local anesthetic blocksbullPudendalperineal
Systemic AnalgesiaTable 25-3 pg 690
bull Pre-medication Assessment bull Pain level VS allergies drug dependence
(withdrawal) vaginal examprogress in labor UC pattern fetal heart rate tracing
bull Post-medication Assessmentbull VS esp RR LOC dizziness (bedpan)
sedation FHRbull Reversal agent Naloxone (Narcan)
bull Competes with narcotic for opiate receptors Used in both mom and baby (avoid with narcotic dependence)
Regional Anesthesiabull Injection of local anesthesia to block
specific nerve pathwaysbull Epiduralspinal anesthesia
bullSystemic toxicity cardiovascular collapsebullSide effects Hypotension (preload with IV
fluids) fetal distress on FHR tracing spinal HA
bullContradindications coagulation disorders low platelet count (lt 100) allergy neurologic disease aspirin use
bullNursing care Preload IV fluids (LR) monitor BP HR anesthesia level FHR foley cath maternal positioning
Epidural Anesthesia
Medication for Pain Relief Birthbull Local anesthesia
bull Pudendal nerve block (2nd stage episiotomy repair)bull Local infiltration in perineum (episiotomy repair)
bull General anesthesiabull Regional contraindicatedemergencybull Preparation hip wedge preoxygenation cricoid
pressure for intubationbull Complications fetal depression aspiration of
vomitus (Bicitra)
Local anesthesia for Episiotomy
Childbirth at Risk (Ch 26)
Complications of Labor or Delivery
Critical Thinking The client in active labor is requesting pain relief The
physician orders epidural anesthesia for the client Which of the following parameters should the nurse
be prepared to assess immediately after administration of the epidural
bull A) For headache bull B) For urinary retention bull C) The blood pressure bull D) The maternal pulse rate
Precipitous Labor amp Birthbull Labor in lt 3 hoursbull Risk factors
bull Multiparity oxytocin or amniotomy hx of precipitate labor
bull Risks for injurybull Maternal cervical vaginal amp perineal
lacerations with possible hemorrhage pain anxiety
bull Fetal Birth trauma (intracranial bleed brachial palsy) meconium-stained fluid fetal distress
bull Management close monitoring for cervical changes induction
Postterm Pregnancybull gt 42 weeksbull Maternal risks traumahemorrhage due
to larger baby uarroperative deliveryc-section
bull Fetal risks placental changes that darroxygenation to baby and uarrmortality rate oligohydramnios (uarrcord compression during labor) LGA baby (uarrbirth trauma shoulder dystocia) meconium aspiration
bull Management gt 40 wks NST BPP or modified BPP (NST amp AFI) induction
Malpresentationsbull Occiput-posterior (OP)
bull Prolonged labor back labor (sacral nerve compression) arrested dilatation descent perineal tears
bull Usually vaginal but may need C-Section if baby doesnrsquot rotate
bull Management positioning (side-lying knee-chest or hand-knees) sacral pressure during UCrsquos
bull Transverse Liebull Associated with pendulous abdomen uterine
massesfibroids congenital abnormalities of uterus hydramnios
bull Attempt External Cephalic Version if unsuccessful obligatory C-section
Malpresentations (cont)bull Breech presentation
Assessment FHT heard high on the abdomen Leopoldrsquos vaginal exam amp USbull Higher risk of anoxia from prolapsed cord traumatic injury to
the after coming head fracture of spine or arm dysfunctional labor
bull Usually delivered by C-section
External Versionbull External cephalic version (37-38 wks) abdominal
manipulation to change fetal presentationbull Contraindications multiple gestation fetal
breech is engaged in pelvis oligohydramnios nonreactive NST nuchal cord vaginal bleeding IUGR ROM
bull Risks immediate cesarean birthbull Nursing actions NPO 8 hrs NST IV line
terbutaline continuous FHR US used to guide manipulations assess for labor fetal distress O- moms need Rhogam following the procedure
MacrosomiaShoulder Dystociabull Wt gt 4500 gms (9-10 lbs)bull Associated with
bull DM Gestational DM Multiparity Postdates obesitybull Risks
bull Shoulder dystocia difficulty delivering the shoulders after head is delivered (obstetrical emergency)
bull Maternal vaginalcervical tears pp hemorrhage rupturebull Fetal compressed cord fractured clavical asphyxia amp neurologic
damage brachial plexus injury (ErbrsquosPalsy)bull SS Turtle signbull Nursing interventions McRoberts maneuvers suprapubic
pressure PP assess for uterine atonyhemorrhage trauma cerebral or neurologic damage to baby
Video youtubecomwatchv=jV6g427UMxYampfeature=related
McRoberts Maneuvers Video
Multiple Gestationbull Monozygotic (identical) twins can have 1 or 2 placentas
chorions or amnions (uarrrisk if all shared)bull Dizygotic (fraternal) twins 2 of everything
bull Dx faster than usual growth of uterus uarrAFP HCG Ultrasound
bull Risks bull Maternal SAB gestational DM HTNpreeclampsiaHELLP
hydramnios PT labor amp deliverybull Fetal Preterm birth twin-to-twin transfusion
Multiple Gestation (cont)bull Management
bull US to determine what type of twinsbull Prevention of PT laborroutine cervical measurements
(US)bull NST surveillance bull Birth depends on maternal amp fetal complications and
fetal position presentationbull Examination of placentabull Close monitoring PP for hemorrhage (atony)
Abruptio Placentaebull Premature separation of placenta from uterine wallbull SS sharp stabbing pain high in fundus heavy
bleeding (may be occult) hard board-like uterus tense painful uterus signs of shock due to blood loss Port-Wine aminotic fluid if ROM
bull Predisposing fx uarrparity adv maternal age short umbilical cord chronic HTN PIH direct trauma vasoconstriction from cocaine or cigarette use
bull Fetal distress on monitor Can progress to DIC
Abruptio Placentae (cont)bull Management
bull Emergency Immediate c-section if birth not imminent
bull Lg gauge IV bull O2 via mask fetal monitoring
maternal VS lateral positioning labs blood transfusion (have 2 units avail)
bull CBC (HampH) Fibrinogen levels platelet count PTPTT fibrin degradation products ( sx of DIC)
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
for pp hemorrhage
bull Table 26-6 pg 746 differential dx abruptioprevia
Low-lying Marginal
Partial Complete
Placenta Previas
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
Diabetes Pulmonary disease Pregnancy-induced hypertension)
bull Chorioamnionitisbull Suspected fetal problems- Intrauterine Growth
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Inductionbull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessmentbull Bishop Score- rating that determines if the cervix
is ready for induction--Pg 765bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole -Inadequate uterine relaxation between contractions lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveriesbull Forceps
bull Indications unable to push arrested descent need a quick delivery breech
bull Associated with maternalfetal birth trauma rectal sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
laborbull Elective
Placenta Factorsbull Placenta previabull Placental abruptionbull Umbilical cord prolapse
Fetal Factorsbull Breech transverse liebull Macrosomiabull Extreme low birth wtbull Fetal distressbull Fetal anomaliesbull Multiple gestation
Cesarean Birth (cont)bull Mortality
morbiditybull 4 x higher than
vaginal birth in US Most risk assoc with emergency c-section
bull Incisionbull Skin vs uterinebull Classical vs low
transverse
bull Maternal Complicationsbull Infectionbull Anesthesia reactionsbull DeepVeinThrombopheb
itisbull Bleedingbull Ureteralbladder injurybull Increase risk for
subsequent pregnancybull Placenta AcretaPrevia
Infertility
Cesarean Birthbull Pre-op CBC w platelets hold clotbull bicitraantacidbull monitor babybull Teaching pre amp post-op anesthesia recovery
breastfeedingbull Psychosocial issues
bull Fearbull Self-imageself-esteem
Post-Op Carebull Assess fundusbleeding vital signs DVTbull Antibiotics bull Pain Duramorph Breakthrough pain
meds Benadryl for itching Zofran for nausea
bull Clear liquids and advance as toleratedbull Assess for GI function Bowel sounds
Passing flatusbull Ambulation Pre-medicate teach splinting
with pillowbull Stool softener
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
multiparity excessive analgesia Afterpains wwwyoutubecomwatchv=EbItF_7KYCcampfeature=related
Fundal Assessment Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina Cervix returns to firm nongravid consistency
by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum Assessment turn pt to side in Simrsquos
position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments Constipation Give stool softeners as
ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis Superficial leg vein disease
ndash Ss tenderness in portion of vein local heat amp redness normal temperature or low-grade fever
ndash Tx local heat elevate limb bed rest analgesia elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation Engorgement day 3 or 4
ndash If breastfeeding Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
Postpartum Complications Postpartum Hemorrhage
ndash CAUSES Uterine atony lacerations retained placental fragments
Risk factorsndash uarr uterine distension multiples polyhydramnios
macrosomia fibroidsndash Trauma rapid or operative birthndash Placental problems previa accreta abruptio
retained placental fragmentsndash Atonic uterus prolonged pitocin magnesium
sulfate or labor uarr maternal age or parity uterine scar chorioamnionitis anemia prior history
ndash Inadequate blood coagulation fetal death or DIC
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
Descent offetal head
Station
Floating
Engaged
At outletcrowning
Dilatation amp Effacement
Care of Laboring PatientEarly Labor
bull Initial physical assessment amp history
bull Admission--rapportbull Fetal amp UC
monitoringbull Vaginal exams q 2
hoursbull Vital signsbull Temperature q 4
hours-intact or q 2 hours ROM
bull Educate regarding labor
bull Encourage comfort position changes bladder emptying
bull Assess pain pain tolerance preferred type of labordelivery
bull Reassure regarding what is normal reduce anxiety
Couple excited talkative pain is manageable
Care of Laboring Patient Active Labor
bull Transition (7-10 cm) Yikes ldquoout of controlrdquo shaking nauseavomiting sweating pain is intensebull Prepare for delivery
bull Second stage (Pushing)bull Educateinstruct regarding pushingbull Assess urge to push and fetal descentbull Encouragemotivate patient assess fatiguebull Monitor fetalmaternal response to pushing
bulge crowningbull Signs of imminent birth perineal bulging
Couple quieter discouraged pain increasing
Stages of LaborSecond Stage
bull Pushing amp descent of baby (STATION)bull Full dilatation (10 cm) to birth
bull Important NOT to push until full dilationbull Assessment Urge to push Rectal
pressurebull Push only with UCrsquosbull Crowning babyrsquos head is visible at the
opening of vaginabull Cardinal movements of labor
youtubecomwatchv=Xath6kOf0NEampfeature=related youtubecomwatchv=duPxBXN4qMgampfeature=related
Mechanisms of labor A B Descent C Internal rotation D Extension E External rotation
Head Rotation during Descent
Crowning
In the hospital
Alternative settings
Crowning
Stages of Labor Third Stage
bull Placental stage from birth to delivery of placenta
bull Placental separation from uterine wall (rise of fundus sudden gush of blood lengthening of umbilical cord)
bull Entire lining of uterus shedbull Expulsion of placenta
bull Normal blood loss 300-500 mLbull If placenta does not deliver spontaneously can
be delivered manuallybull Pitocin infusion started immediately post
delivery of placenta
Critical Thinkingbull
A client is admitted to the labor unit with contractions 2 to 3 minutes apart and lasting 60 to 90 seconds The client is apprehensive and vomiting This nurse understands this information to indicate that the client is most likely in what phase of labor
bull A) Active bull B) Transition bull C) Latent bull D) Second
Chapter 23Intrapartal Nursing Assessment
Initial Intrapartum AssessmentPages 608-612
bull Vital signsbull Fetal heart rate pattern fetal distressbull Contraction pattern intensity painbull Membrane status--intact ruptured nitrizine test
amniotic fluid clear meconium foul odorbull Prenatal records history of pregnancy
complications previous pregnancies and deliveries maternal health problems
bull Psychosocialfamilycultural issuesbull Labs CBC dip urine for protein glucose
ketonesbull Vaginal Exam--effacementdilationstation fetal
presentationlie Assesses LABOR PROGRESS
Intrauterine Fetal Resuscitation
bull Stop pitocinbull Reposition to left lateral Trendelenberg if neededbull Oxygen via mask at 8-10 Lminbull Increase IV fluidsbull SQ terbutaline (025 mg) if uterus not relaxingbull Vaginal exam for possible cause prolapse fetal
descent rupture abruptionbull Amnioinfusion for variable decelsbull Notify MDmidwife
Which strip shows signs thatImmediate intervention is needed Why What would you do
A
B
Experiences of Painbull Etiology bull Physiologybull Perception
bull Factors influencingAnxiety Psychological factorsExpectations Cultural factorsSupport Fetal position
Comfort and Pain Relief
bull Support from doula or coachbull Alternative therapies
bullRelaxationmassagebull Focusing and imagerybullBreathingbullHerbal preparationsaromatherapybullHypnosis
Comfort and Pain Reliefbull Pharmacological Measures
bullNarcotic analgesicsbullNubainStadolDemerol (pg 689)
bullRegional nerve blocksbullEpiduralspinal
bull Local anesthetic blocksbullPudendalperineal
Systemic AnalgesiaTable 25-3 pg 690
bull Pre-medication Assessment bull Pain level VS allergies drug dependence
(withdrawal) vaginal examprogress in labor UC pattern fetal heart rate tracing
bull Post-medication Assessmentbull VS esp RR LOC dizziness (bedpan)
sedation FHRbull Reversal agent Naloxone (Narcan)
bull Competes with narcotic for opiate receptors Used in both mom and baby (avoid with narcotic dependence)
Regional Anesthesiabull Injection of local anesthesia to block
specific nerve pathwaysbull Epiduralspinal anesthesia
bullSystemic toxicity cardiovascular collapsebullSide effects Hypotension (preload with IV
fluids) fetal distress on FHR tracing spinal HA
bullContradindications coagulation disorders low platelet count (lt 100) allergy neurologic disease aspirin use
bullNursing care Preload IV fluids (LR) monitor BP HR anesthesia level FHR foley cath maternal positioning
Epidural Anesthesia
Medication for Pain Relief Birthbull Local anesthesia
bull Pudendal nerve block (2nd stage episiotomy repair)bull Local infiltration in perineum (episiotomy repair)
bull General anesthesiabull Regional contraindicatedemergencybull Preparation hip wedge preoxygenation cricoid
pressure for intubationbull Complications fetal depression aspiration of
vomitus (Bicitra)
Local anesthesia for Episiotomy
Childbirth at Risk (Ch 26)
Complications of Labor or Delivery
Critical Thinking The client in active labor is requesting pain relief The
physician orders epidural anesthesia for the client Which of the following parameters should the nurse
be prepared to assess immediately after administration of the epidural
bull A) For headache bull B) For urinary retention bull C) The blood pressure bull D) The maternal pulse rate
Precipitous Labor amp Birthbull Labor in lt 3 hoursbull Risk factors
bull Multiparity oxytocin or amniotomy hx of precipitate labor
bull Risks for injurybull Maternal cervical vaginal amp perineal
lacerations with possible hemorrhage pain anxiety
bull Fetal Birth trauma (intracranial bleed brachial palsy) meconium-stained fluid fetal distress
bull Management close monitoring for cervical changes induction
Postterm Pregnancybull gt 42 weeksbull Maternal risks traumahemorrhage due
to larger baby uarroperative deliveryc-section
bull Fetal risks placental changes that darroxygenation to baby and uarrmortality rate oligohydramnios (uarrcord compression during labor) LGA baby (uarrbirth trauma shoulder dystocia) meconium aspiration
bull Management gt 40 wks NST BPP or modified BPP (NST amp AFI) induction
Malpresentationsbull Occiput-posterior (OP)
bull Prolonged labor back labor (sacral nerve compression) arrested dilatation descent perineal tears
bull Usually vaginal but may need C-Section if baby doesnrsquot rotate
bull Management positioning (side-lying knee-chest or hand-knees) sacral pressure during UCrsquos
bull Transverse Liebull Associated with pendulous abdomen uterine
massesfibroids congenital abnormalities of uterus hydramnios
bull Attempt External Cephalic Version if unsuccessful obligatory C-section
Malpresentations (cont)bull Breech presentation
Assessment FHT heard high on the abdomen Leopoldrsquos vaginal exam amp USbull Higher risk of anoxia from prolapsed cord traumatic injury to
the after coming head fracture of spine or arm dysfunctional labor
bull Usually delivered by C-section
External Versionbull External cephalic version (37-38 wks) abdominal
manipulation to change fetal presentationbull Contraindications multiple gestation fetal
breech is engaged in pelvis oligohydramnios nonreactive NST nuchal cord vaginal bleeding IUGR ROM
bull Risks immediate cesarean birthbull Nursing actions NPO 8 hrs NST IV line
terbutaline continuous FHR US used to guide manipulations assess for labor fetal distress O- moms need Rhogam following the procedure
MacrosomiaShoulder Dystociabull Wt gt 4500 gms (9-10 lbs)bull Associated with
bull DM Gestational DM Multiparity Postdates obesitybull Risks
bull Shoulder dystocia difficulty delivering the shoulders after head is delivered (obstetrical emergency)
bull Maternal vaginalcervical tears pp hemorrhage rupturebull Fetal compressed cord fractured clavical asphyxia amp neurologic
damage brachial plexus injury (ErbrsquosPalsy)bull SS Turtle signbull Nursing interventions McRoberts maneuvers suprapubic
pressure PP assess for uterine atonyhemorrhage trauma cerebral or neurologic damage to baby
Video youtubecomwatchv=jV6g427UMxYampfeature=related
McRoberts Maneuvers Video
Multiple Gestationbull Monozygotic (identical) twins can have 1 or 2 placentas
chorions or amnions (uarrrisk if all shared)bull Dizygotic (fraternal) twins 2 of everything
bull Dx faster than usual growth of uterus uarrAFP HCG Ultrasound
bull Risks bull Maternal SAB gestational DM HTNpreeclampsiaHELLP
hydramnios PT labor amp deliverybull Fetal Preterm birth twin-to-twin transfusion
Multiple Gestation (cont)bull Management
bull US to determine what type of twinsbull Prevention of PT laborroutine cervical measurements
(US)bull NST surveillance bull Birth depends on maternal amp fetal complications and
fetal position presentationbull Examination of placentabull Close monitoring PP for hemorrhage (atony)
Abruptio Placentaebull Premature separation of placenta from uterine wallbull SS sharp stabbing pain high in fundus heavy
bleeding (may be occult) hard board-like uterus tense painful uterus signs of shock due to blood loss Port-Wine aminotic fluid if ROM
bull Predisposing fx uarrparity adv maternal age short umbilical cord chronic HTN PIH direct trauma vasoconstriction from cocaine or cigarette use
bull Fetal distress on monitor Can progress to DIC
Abruptio Placentae (cont)bull Management
bull Emergency Immediate c-section if birth not imminent
bull Lg gauge IV bull O2 via mask fetal monitoring
maternal VS lateral positioning labs blood transfusion (have 2 units avail)
bull CBC (HampH) Fibrinogen levels platelet count PTPTT fibrin degradation products ( sx of DIC)
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
for pp hemorrhage
bull Table 26-6 pg 746 differential dx abruptioprevia
Low-lying Marginal
Partial Complete
Placenta Previas
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
Diabetes Pulmonary disease Pregnancy-induced hypertension)
bull Chorioamnionitisbull Suspected fetal problems- Intrauterine Growth
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Inductionbull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessmentbull Bishop Score- rating that determines if the cervix
is ready for induction--Pg 765bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole -Inadequate uterine relaxation between contractions lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveriesbull Forceps
bull Indications unable to push arrested descent need a quick delivery breech
bull Associated with maternalfetal birth trauma rectal sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
laborbull Elective
Placenta Factorsbull Placenta previabull Placental abruptionbull Umbilical cord prolapse
Fetal Factorsbull Breech transverse liebull Macrosomiabull Extreme low birth wtbull Fetal distressbull Fetal anomaliesbull Multiple gestation
Cesarean Birth (cont)bull Mortality
morbiditybull 4 x higher than
vaginal birth in US Most risk assoc with emergency c-section
bull Incisionbull Skin vs uterinebull Classical vs low
transverse
bull Maternal Complicationsbull Infectionbull Anesthesia reactionsbull DeepVeinThrombopheb
itisbull Bleedingbull Ureteralbladder injurybull Increase risk for
subsequent pregnancybull Placenta AcretaPrevia
Infertility
Cesarean Birthbull Pre-op CBC w platelets hold clotbull bicitraantacidbull monitor babybull Teaching pre amp post-op anesthesia recovery
breastfeedingbull Psychosocial issues
bull Fearbull Self-imageself-esteem
Post-Op Carebull Assess fundusbleeding vital signs DVTbull Antibiotics bull Pain Duramorph Breakthrough pain
meds Benadryl for itching Zofran for nausea
bull Clear liquids and advance as toleratedbull Assess for GI function Bowel sounds
Passing flatusbull Ambulation Pre-medicate teach splinting
with pillowbull Stool softener
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
multiparity excessive analgesia Afterpains wwwyoutubecomwatchv=EbItF_7KYCcampfeature=related
Fundal Assessment Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina Cervix returns to firm nongravid consistency
by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum Assessment turn pt to side in Simrsquos
position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments Constipation Give stool softeners as
ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis Superficial leg vein disease
ndash Ss tenderness in portion of vein local heat amp redness normal temperature or low-grade fever
ndash Tx local heat elevate limb bed rest analgesia elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation Engorgement day 3 or 4
ndash If breastfeeding Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
Postpartum Complications Postpartum Hemorrhage
ndash CAUSES Uterine atony lacerations retained placental fragments
Risk factorsndash uarr uterine distension multiples polyhydramnios
macrosomia fibroidsndash Trauma rapid or operative birthndash Placental problems previa accreta abruptio
retained placental fragmentsndash Atonic uterus prolonged pitocin magnesium
sulfate or labor uarr maternal age or parity uterine scar chorioamnionitis anemia prior history
ndash Inadequate blood coagulation fetal death or DIC
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
Dilatation amp Effacement
Care of Laboring PatientEarly Labor
bull Initial physical assessment amp history
bull Admission--rapportbull Fetal amp UC
monitoringbull Vaginal exams q 2
hoursbull Vital signsbull Temperature q 4
hours-intact or q 2 hours ROM
bull Educate regarding labor
bull Encourage comfort position changes bladder emptying
bull Assess pain pain tolerance preferred type of labordelivery
bull Reassure regarding what is normal reduce anxiety
Couple excited talkative pain is manageable
Care of Laboring Patient Active Labor
bull Transition (7-10 cm) Yikes ldquoout of controlrdquo shaking nauseavomiting sweating pain is intensebull Prepare for delivery
bull Second stage (Pushing)bull Educateinstruct regarding pushingbull Assess urge to push and fetal descentbull Encouragemotivate patient assess fatiguebull Monitor fetalmaternal response to pushing
bulge crowningbull Signs of imminent birth perineal bulging
Couple quieter discouraged pain increasing
Stages of LaborSecond Stage
bull Pushing amp descent of baby (STATION)bull Full dilatation (10 cm) to birth
bull Important NOT to push until full dilationbull Assessment Urge to push Rectal
pressurebull Push only with UCrsquosbull Crowning babyrsquos head is visible at the
opening of vaginabull Cardinal movements of labor
youtubecomwatchv=Xath6kOf0NEampfeature=related youtubecomwatchv=duPxBXN4qMgampfeature=related
Mechanisms of labor A B Descent C Internal rotation D Extension E External rotation
Head Rotation during Descent
Crowning
In the hospital
Alternative settings
Crowning
Stages of Labor Third Stage
bull Placental stage from birth to delivery of placenta
bull Placental separation from uterine wall (rise of fundus sudden gush of blood lengthening of umbilical cord)
bull Entire lining of uterus shedbull Expulsion of placenta
bull Normal blood loss 300-500 mLbull If placenta does not deliver spontaneously can
be delivered manuallybull Pitocin infusion started immediately post
delivery of placenta
Critical Thinkingbull
A client is admitted to the labor unit with contractions 2 to 3 minutes apart and lasting 60 to 90 seconds The client is apprehensive and vomiting This nurse understands this information to indicate that the client is most likely in what phase of labor
bull A) Active bull B) Transition bull C) Latent bull D) Second
Chapter 23Intrapartal Nursing Assessment
Initial Intrapartum AssessmentPages 608-612
bull Vital signsbull Fetal heart rate pattern fetal distressbull Contraction pattern intensity painbull Membrane status--intact ruptured nitrizine test
amniotic fluid clear meconium foul odorbull Prenatal records history of pregnancy
complications previous pregnancies and deliveries maternal health problems
bull Psychosocialfamilycultural issuesbull Labs CBC dip urine for protein glucose
ketonesbull Vaginal Exam--effacementdilationstation fetal
presentationlie Assesses LABOR PROGRESS
Intrauterine Fetal Resuscitation
bull Stop pitocinbull Reposition to left lateral Trendelenberg if neededbull Oxygen via mask at 8-10 Lminbull Increase IV fluidsbull SQ terbutaline (025 mg) if uterus not relaxingbull Vaginal exam for possible cause prolapse fetal
descent rupture abruptionbull Amnioinfusion for variable decelsbull Notify MDmidwife
Which strip shows signs thatImmediate intervention is needed Why What would you do
A
B
Experiences of Painbull Etiology bull Physiologybull Perception
bull Factors influencingAnxiety Psychological factorsExpectations Cultural factorsSupport Fetal position
Comfort and Pain Relief
bull Support from doula or coachbull Alternative therapies
bullRelaxationmassagebull Focusing and imagerybullBreathingbullHerbal preparationsaromatherapybullHypnosis
Comfort and Pain Reliefbull Pharmacological Measures
bullNarcotic analgesicsbullNubainStadolDemerol (pg 689)
bullRegional nerve blocksbullEpiduralspinal
bull Local anesthetic blocksbullPudendalperineal
Systemic AnalgesiaTable 25-3 pg 690
bull Pre-medication Assessment bull Pain level VS allergies drug dependence
(withdrawal) vaginal examprogress in labor UC pattern fetal heart rate tracing
bull Post-medication Assessmentbull VS esp RR LOC dizziness (bedpan)
sedation FHRbull Reversal agent Naloxone (Narcan)
bull Competes with narcotic for opiate receptors Used in both mom and baby (avoid with narcotic dependence)
Regional Anesthesiabull Injection of local anesthesia to block
specific nerve pathwaysbull Epiduralspinal anesthesia
bullSystemic toxicity cardiovascular collapsebullSide effects Hypotension (preload with IV
fluids) fetal distress on FHR tracing spinal HA
bullContradindications coagulation disorders low platelet count (lt 100) allergy neurologic disease aspirin use
bullNursing care Preload IV fluids (LR) monitor BP HR anesthesia level FHR foley cath maternal positioning
Epidural Anesthesia
Medication for Pain Relief Birthbull Local anesthesia
bull Pudendal nerve block (2nd stage episiotomy repair)bull Local infiltration in perineum (episiotomy repair)
bull General anesthesiabull Regional contraindicatedemergencybull Preparation hip wedge preoxygenation cricoid
pressure for intubationbull Complications fetal depression aspiration of
vomitus (Bicitra)
Local anesthesia for Episiotomy
Childbirth at Risk (Ch 26)
Complications of Labor or Delivery
Critical Thinking The client in active labor is requesting pain relief The
physician orders epidural anesthesia for the client Which of the following parameters should the nurse
be prepared to assess immediately after administration of the epidural
bull A) For headache bull B) For urinary retention bull C) The blood pressure bull D) The maternal pulse rate
Precipitous Labor amp Birthbull Labor in lt 3 hoursbull Risk factors
bull Multiparity oxytocin or amniotomy hx of precipitate labor
bull Risks for injurybull Maternal cervical vaginal amp perineal
lacerations with possible hemorrhage pain anxiety
bull Fetal Birth trauma (intracranial bleed brachial palsy) meconium-stained fluid fetal distress
bull Management close monitoring for cervical changes induction
Postterm Pregnancybull gt 42 weeksbull Maternal risks traumahemorrhage due
to larger baby uarroperative deliveryc-section
bull Fetal risks placental changes that darroxygenation to baby and uarrmortality rate oligohydramnios (uarrcord compression during labor) LGA baby (uarrbirth trauma shoulder dystocia) meconium aspiration
bull Management gt 40 wks NST BPP or modified BPP (NST amp AFI) induction
Malpresentationsbull Occiput-posterior (OP)
bull Prolonged labor back labor (sacral nerve compression) arrested dilatation descent perineal tears
bull Usually vaginal but may need C-Section if baby doesnrsquot rotate
bull Management positioning (side-lying knee-chest or hand-knees) sacral pressure during UCrsquos
bull Transverse Liebull Associated with pendulous abdomen uterine
massesfibroids congenital abnormalities of uterus hydramnios
bull Attempt External Cephalic Version if unsuccessful obligatory C-section
Malpresentations (cont)bull Breech presentation
Assessment FHT heard high on the abdomen Leopoldrsquos vaginal exam amp USbull Higher risk of anoxia from prolapsed cord traumatic injury to
the after coming head fracture of spine or arm dysfunctional labor
bull Usually delivered by C-section
External Versionbull External cephalic version (37-38 wks) abdominal
manipulation to change fetal presentationbull Contraindications multiple gestation fetal
breech is engaged in pelvis oligohydramnios nonreactive NST nuchal cord vaginal bleeding IUGR ROM
bull Risks immediate cesarean birthbull Nursing actions NPO 8 hrs NST IV line
terbutaline continuous FHR US used to guide manipulations assess for labor fetal distress O- moms need Rhogam following the procedure
MacrosomiaShoulder Dystociabull Wt gt 4500 gms (9-10 lbs)bull Associated with
bull DM Gestational DM Multiparity Postdates obesitybull Risks
bull Shoulder dystocia difficulty delivering the shoulders after head is delivered (obstetrical emergency)
bull Maternal vaginalcervical tears pp hemorrhage rupturebull Fetal compressed cord fractured clavical asphyxia amp neurologic
damage brachial plexus injury (ErbrsquosPalsy)bull SS Turtle signbull Nursing interventions McRoberts maneuvers suprapubic
pressure PP assess for uterine atonyhemorrhage trauma cerebral or neurologic damage to baby
Video youtubecomwatchv=jV6g427UMxYampfeature=related
McRoberts Maneuvers Video
Multiple Gestationbull Monozygotic (identical) twins can have 1 or 2 placentas
chorions or amnions (uarrrisk if all shared)bull Dizygotic (fraternal) twins 2 of everything
bull Dx faster than usual growth of uterus uarrAFP HCG Ultrasound
bull Risks bull Maternal SAB gestational DM HTNpreeclampsiaHELLP
hydramnios PT labor amp deliverybull Fetal Preterm birth twin-to-twin transfusion
Multiple Gestation (cont)bull Management
bull US to determine what type of twinsbull Prevention of PT laborroutine cervical measurements
(US)bull NST surveillance bull Birth depends on maternal amp fetal complications and
fetal position presentationbull Examination of placentabull Close monitoring PP for hemorrhage (atony)
Abruptio Placentaebull Premature separation of placenta from uterine wallbull SS sharp stabbing pain high in fundus heavy
bleeding (may be occult) hard board-like uterus tense painful uterus signs of shock due to blood loss Port-Wine aminotic fluid if ROM
bull Predisposing fx uarrparity adv maternal age short umbilical cord chronic HTN PIH direct trauma vasoconstriction from cocaine or cigarette use
bull Fetal distress on monitor Can progress to DIC
Abruptio Placentae (cont)bull Management
bull Emergency Immediate c-section if birth not imminent
bull Lg gauge IV bull O2 via mask fetal monitoring
maternal VS lateral positioning labs blood transfusion (have 2 units avail)
bull CBC (HampH) Fibrinogen levels platelet count PTPTT fibrin degradation products ( sx of DIC)
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
for pp hemorrhage
bull Table 26-6 pg 746 differential dx abruptioprevia
Low-lying Marginal
Partial Complete
Placenta Previas
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
Diabetes Pulmonary disease Pregnancy-induced hypertension)
bull Chorioamnionitisbull Suspected fetal problems- Intrauterine Growth
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Inductionbull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessmentbull Bishop Score- rating that determines if the cervix
is ready for induction--Pg 765bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole -Inadequate uterine relaxation between contractions lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveriesbull Forceps
bull Indications unable to push arrested descent need a quick delivery breech
bull Associated with maternalfetal birth trauma rectal sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
laborbull Elective
Placenta Factorsbull Placenta previabull Placental abruptionbull Umbilical cord prolapse
Fetal Factorsbull Breech transverse liebull Macrosomiabull Extreme low birth wtbull Fetal distressbull Fetal anomaliesbull Multiple gestation
Cesarean Birth (cont)bull Mortality
morbiditybull 4 x higher than
vaginal birth in US Most risk assoc with emergency c-section
bull Incisionbull Skin vs uterinebull Classical vs low
transverse
bull Maternal Complicationsbull Infectionbull Anesthesia reactionsbull DeepVeinThrombopheb
itisbull Bleedingbull Ureteralbladder injurybull Increase risk for
subsequent pregnancybull Placenta AcretaPrevia
Infertility
Cesarean Birthbull Pre-op CBC w platelets hold clotbull bicitraantacidbull monitor babybull Teaching pre amp post-op anesthesia recovery
breastfeedingbull Psychosocial issues
bull Fearbull Self-imageself-esteem
Post-Op Carebull Assess fundusbleeding vital signs DVTbull Antibiotics bull Pain Duramorph Breakthrough pain
meds Benadryl for itching Zofran for nausea
bull Clear liquids and advance as toleratedbull Assess for GI function Bowel sounds
Passing flatusbull Ambulation Pre-medicate teach splinting
with pillowbull Stool softener
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
multiparity excessive analgesia Afterpains wwwyoutubecomwatchv=EbItF_7KYCcampfeature=related
Fundal Assessment Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina Cervix returns to firm nongravid consistency
by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum Assessment turn pt to side in Simrsquos
position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments Constipation Give stool softeners as
ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis Superficial leg vein disease
ndash Ss tenderness in portion of vein local heat amp redness normal temperature or low-grade fever
ndash Tx local heat elevate limb bed rest analgesia elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation Engorgement day 3 or 4
ndash If breastfeeding Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
Postpartum Complications Postpartum Hemorrhage
ndash CAUSES Uterine atony lacerations retained placental fragments
Risk factorsndash uarr uterine distension multiples polyhydramnios
macrosomia fibroidsndash Trauma rapid or operative birthndash Placental problems previa accreta abruptio
retained placental fragmentsndash Atonic uterus prolonged pitocin magnesium
sulfate or labor uarr maternal age or parity uterine scar chorioamnionitis anemia prior history
ndash Inadequate blood coagulation fetal death or DIC
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
Care of Laboring PatientEarly Labor
bull Initial physical assessment amp history
bull Admission--rapportbull Fetal amp UC
monitoringbull Vaginal exams q 2
hoursbull Vital signsbull Temperature q 4
hours-intact or q 2 hours ROM
bull Educate regarding labor
bull Encourage comfort position changes bladder emptying
bull Assess pain pain tolerance preferred type of labordelivery
bull Reassure regarding what is normal reduce anxiety
Couple excited talkative pain is manageable
Care of Laboring Patient Active Labor
bull Transition (7-10 cm) Yikes ldquoout of controlrdquo shaking nauseavomiting sweating pain is intensebull Prepare for delivery
bull Second stage (Pushing)bull Educateinstruct regarding pushingbull Assess urge to push and fetal descentbull Encouragemotivate patient assess fatiguebull Monitor fetalmaternal response to pushing
bulge crowningbull Signs of imminent birth perineal bulging
Couple quieter discouraged pain increasing
Stages of LaborSecond Stage
bull Pushing amp descent of baby (STATION)bull Full dilatation (10 cm) to birth
bull Important NOT to push until full dilationbull Assessment Urge to push Rectal
pressurebull Push only with UCrsquosbull Crowning babyrsquos head is visible at the
opening of vaginabull Cardinal movements of labor
youtubecomwatchv=Xath6kOf0NEampfeature=related youtubecomwatchv=duPxBXN4qMgampfeature=related
Mechanisms of labor A B Descent C Internal rotation D Extension E External rotation
Head Rotation during Descent
Crowning
In the hospital
Alternative settings
Crowning
Stages of Labor Third Stage
bull Placental stage from birth to delivery of placenta
bull Placental separation from uterine wall (rise of fundus sudden gush of blood lengthening of umbilical cord)
bull Entire lining of uterus shedbull Expulsion of placenta
bull Normal blood loss 300-500 mLbull If placenta does not deliver spontaneously can
be delivered manuallybull Pitocin infusion started immediately post
delivery of placenta
Critical Thinkingbull
A client is admitted to the labor unit with contractions 2 to 3 minutes apart and lasting 60 to 90 seconds The client is apprehensive and vomiting This nurse understands this information to indicate that the client is most likely in what phase of labor
bull A) Active bull B) Transition bull C) Latent bull D) Second
Chapter 23Intrapartal Nursing Assessment
Initial Intrapartum AssessmentPages 608-612
bull Vital signsbull Fetal heart rate pattern fetal distressbull Contraction pattern intensity painbull Membrane status--intact ruptured nitrizine test
amniotic fluid clear meconium foul odorbull Prenatal records history of pregnancy
complications previous pregnancies and deliveries maternal health problems
bull Psychosocialfamilycultural issuesbull Labs CBC dip urine for protein glucose
ketonesbull Vaginal Exam--effacementdilationstation fetal
presentationlie Assesses LABOR PROGRESS
Intrauterine Fetal Resuscitation
bull Stop pitocinbull Reposition to left lateral Trendelenberg if neededbull Oxygen via mask at 8-10 Lminbull Increase IV fluidsbull SQ terbutaline (025 mg) if uterus not relaxingbull Vaginal exam for possible cause prolapse fetal
descent rupture abruptionbull Amnioinfusion for variable decelsbull Notify MDmidwife
Which strip shows signs thatImmediate intervention is needed Why What would you do
A
B
Experiences of Painbull Etiology bull Physiologybull Perception
bull Factors influencingAnxiety Psychological factorsExpectations Cultural factorsSupport Fetal position
Comfort and Pain Relief
bull Support from doula or coachbull Alternative therapies
bullRelaxationmassagebull Focusing and imagerybullBreathingbullHerbal preparationsaromatherapybullHypnosis
Comfort and Pain Reliefbull Pharmacological Measures
bullNarcotic analgesicsbullNubainStadolDemerol (pg 689)
bullRegional nerve blocksbullEpiduralspinal
bull Local anesthetic blocksbullPudendalperineal
Systemic AnalgesiaTable 25-3 pg 690
bull Pre-medication Assessment bull Pain level VS allergies drug dependence
(withdrawal) vaginal examprogress in labor UC pattern fetal heart rate tracing
bull Post-medication Assessmentbull VS esp RR LOC dizziness (bedpan)
sedation FHRbull Reversal agent Naloxone (Narcan)
bull Competes with narcotic for opiate receptors Used in both mom and baby (avoid with narcotic dependence)
Regional Anesthesiabull Injection of local anesthesia to block
specific nerve pathwaysbull Epiduralspinal anesthesia
bullSystemic toxicity cardiovascular collapsebullSide effects Hypotension (preload with IV
fluids) fetal distress on FHR tracing spinal HA
bullContradindications coagulation disorders low platelet count (lt 100) allergy neurologic disease aspirin use
bullNursing care Preload IV fluids (LR) monitor BP HR anesthesia level FHR foley cath maternal positioning
Epidural Anesthesia
Medication for Pain Relief Birthbull Local anesthesia
bull Pudendal nerve block (2nd stage episiotomy repair)bull Local infiltration in perineum (episiotomy repair)
bull General anesthesiabull Regional contraindicatedemergencybull Preparation hip wedge preoxygenation cricoid
pressure for intubationbull Complications fetal depression aspiration of
vomitus (Bicitra)
Local anesthesia for Episiotomy
Childbirth at Risk (Ch 26)
Complications of Labor or Delivery
Critical Thinking The client in active labor is requesting pain relief The
physician orders epidural anesthesia for the client Which of the following parameters should the nurse
be prepared to assess immediately after administration of the epidural
bull A) For headache bull B) For urinary retention bull C) The blood pressure bull D) The maternal pulse rate
Precipitous Labor amp Birthbull Labor in lt 3 hoursbull Risk factors
bull Multiparity oxytocin or amniotomy hx of precipitate labor
bull Risks for injurybull Maternal cervical vaginal amp perineal
lacerations with possible hemorrhage pain anxiety
bull Fetal Birth trauma (intracranial bleed brachial palsy) meconium-stained fluid fetal distress
bull Management close monitoring for cervical changes induction
Postterm Pregnancybull gt 42 weeksbull Maternal risks traumahemorrhage due
to larger baby uarroperative deliveryc-section
bull Fetal risks placental changes that darroxygenation to baby and uarrmortality rate oligohydramnios (uarrcord compression during labor) LGA baby (uarrbirth trauma shoulder dystocia) meconium aspiration
bull Management gt 40 wks NST BPP or modified BPP (NST amp AFI) induction
Malpresentationsbull Occiput-posterior (OP)
bull Prolonged labor back labor (sacral nerve compression) arrested dilatation descent perineal tears
bull Usually vaginal but may need C-Section if baby doesnrsquot rotate
bull Management positioning (side-lying knee-chest or hand-knees) sacral pressure during UCrsquos
bull Transverse Liebull Associated with pendulous abdomen uterine
massesfibroids congenital abnormalities of uterus hydramnios
bull Attempt External Cephalic Version if unsuccessful obligatory C-section
Malpresentations (cont)bull Breech presentation
Assessment FHT heard high on the abdomen Leopoldrsquos vaginal exam amp USbull Higher risk of anoxia from prolapsed cord traumatic injury to
the after coming head fracture of spine or arm dysfunctional labor
bull Usually delivered by C-section
External Versionbull External cephalic version (37-38 wks) abdominal
manipulation to change fetal presentationbull Contraindications multiple gestation fetal
breech is engaged in pelvis oligohydramnios nonreactive NST nuchal cord vaginal bleeding IUGR ROM
bull Risks immediate cesarean birthbull Nursing actions NPO 8 hrs NST IV line
terbutaline continuous FHR US used to guide manipulations assess for labor fetal distress O- moms need Rhogam following the procedure
MacrosomiaShoulder Dystociabull Wt gt 4500 gms (9-10 lbs)bull Associated with
bull DM Gestational DM Multiparity Postdates obesitybull Risks
bull Shoulder dystocia difficulty delivering the shoulders after head is delivered (obstetrical emergency)
bull Maternal vaginalcervical tears pp hemorrhage rupturebull Fetal compressed cord fractured clavical asphyxia amp neurologic
damage brachial plexus injury (ErbrsquosPalsy)bull SS Turtle signbull Nursing interventions McRoberts maneuvers suprapubic
pressure PP assess for uterine atonyhemorrhage trauma cerebral or neurologic damage to baby
Video youtubecomwatchv=jV6g427UMxYampfeature=related
McRoberts Maneuvers Video
Multiple Gestationbull Monozygotic (identical) twins can have 1 or 2 placentas
chorions or amnions (uarrrisk if all shared)bull Dizygotic (fraternal) twins 2 of everything
bull Dx faster than usual growth of uterus uarrAFP HCG Ultrasound
bull Risks bull Maternal SAB gestational DM HTNpreeclampsiaHELLP
hydramnios PT labor amp deliverybull Fetal Preterm birth twin-to-twin transfusion
Multiple Gestation (cont)bull Management
bull US to determine what type of twinsbull Prevention of PT laborroutine cervical measurements
(US)bull NST surveillance bull Birth depends on maternal amp fetal complications and
fetal position presentationbull Examination of placentabull Close monitoring PP for hemorrhage (atony)
Abruptio Placentaebull Premature separation of placenta from uterine wallbull SS sharp stabbing pain high in fundus heavy
bleeding (may be occult) hard board-like uterus tense painful uterus signs of shock due to blood loss Port-Wine aminotic fluid if ROM
bull Predisposing fx uarrparity adv maternal age short umbilical cord chronic HTN PIH direct trauma vasoconstriction from cocaine or cigarette use
bull Fetal distress on monitor Can progress to DIC
Abruptio Placentae (cont)bull Management
bull Emergency Immediate c-section if birth not imminent
bull Lg gauge IV bull O2 via mask fetal monitoring
maternal VS lateral positioning labs blood transfusion (have 2 units avail)
bull CBC (HampH) Fibrinogen levels platelet count PTPTT fibrin degradation products ( sx of DIC)
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
for pp hemorrhage
bull Table 26-6 pg 746 differential dx abruptioprevia
Low-lying Marginal
Partial Complete
Placenta Previas
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
Diabetes Pulmonary disease Pregnancy-induced hypertension)
bull Chorioamnionitisbull Suspected fetal problems- Intrauterine Growth
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Inductionbull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessmentbull Bishop Score- rating that determines if the cervix
is ready for induction--Pg 765bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole -Inadequate uterine relaxation between contractions lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveriesbull Forceps
bull Indications unable to push arrested descent need a quick delivery breech
bull Associated with maternalfetal birth trauma rectal sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
laborbull Elective
Placenta Factorsbull Placenta previabull Placental abruptionbull Umbilical cord prolapse
Fetal Factorsbull Breech transverse liebull Macrosomiabull Extreme low birth wtbull Fetal distressbull Fetal anomaliesbull Multiple gestation
Cesarean Birth (cont)bull Mortality
morbiditybull 4 x higher than
vaginal birth in US Most risk assoc with emergency c-section
bull Incisionbull Skin vs uterinebull Classical vs low
transverse
bull Maternal Complicationsbull Infectionbull Anesthesia reactionsbull DeepVeinThrombopheb
itisbull Bleedingbull Ureteralbladder injurybull Increase risk for
subsequent pregnancybull Placenta AcretaPrevia
Infertility
Cesarean Birthbull Pre-op CBC w platelets hold clotbull bicitraantacidbull monitor babybull Teaching pre amp post-op anesthesia recovery
breastfeedingbull Psychosocial issues
bull Fearbull Self-imageself-esteem
Post-Op Carebull Assess fundusbleeding vital signs DVTbull Antibiotics bull Pain Duramorph Breakthrough pain
meds Benadryl for itching Zofran for nausea
bull Clear liquids and advance as toleratedbull Assess for GI function Bowel sounds
Passing flatusbull Ambulation Pre-medicate teach splinting
with pillowbull Stool softener
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
multiparity excessive analgesia Afterpains wwwyoutubecomwatchv=EbItF_7KYCcampfeature=related
Fundal Assessment Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina Cervix returns to firm nongravid consistency
by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum Assessment turn pt to side in Simrsquos
position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments Constipation Give stool softeners as
ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis Superficial leg vein disease
ndash Ss tenderness in portion of vein local heat amp redness normal temperature or low-grade fever
ndash Tx local heat elevate limb bed rest analgesia elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation Engorgement day 3 or 4
ndash If breastfeeding Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
Postpartum Complications Postpartum Hemorrhage
ndash CAUSES Uterine atony lacerations retained placental fragments
Risk factorsndash uarr uterine distension multiples polyhydramnios
macrosomia fibroidsndash Trauma rapid or operative birthndash Placental problems previa accreta abruptio
retained placental fragmentsndash Atonic uterus prolonged pitocin magnesium
sulfate or labor uarr maternal age or parity uterine scar chorioamnionitis anemia prior history
ndash Inadequate blood coagulation fetal death or DIC
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
Care of Laboring Patient Active Labor
bull Transition (7-10 cm) Yikes ldquoout of controlrdquo shaking nauseavomiting sweating pain is intensebull Prepare for delivery
bull Second stage (Pushing)bull Educateinstruct regarding pushingbull Assess urge to push and fetal descentbull Encouragemotivate patient assess fatiguebull Monitor fetalmaternal response to pushing
bulge crowningbull Signs of imminent birth perineal bulging
Couple quieter discouraged pain increasing
Stages of LaborSecond Stage
bull Pushing amp descent of baby (STATION)bull Full dilatation (10 cm) to birth
bull Important NOT to push until full dilationbull Assessment Urge to push Rectal
pressurebull Push only with UCrsquosbull Crowning babyrsquos head is visible at the
opening of vaginabull Cardinal movements of labor
youtubecomwatchv=Xath6kOf0NEampfeature=related youtubecomwatchv=duPxBXN4qMgampfeature=related
Mechanisms of labor A B Descent C Internal rotation D Extension E External rotation
Head Rotation during Descent
Crowning
In the hospital
Alternative settings
Crowning
Stages of Labor Third Stage
bull Placental stage from birth to delivery of placenta
bull Placental separation from uterine wall (rise of fundus sudden gush of blood lengthening of umbilical cord)
bull Entire lining of uterus shedbull Expulsion of placenta
bull Normal blood loss 300-500 mLbull If placenta does not deliver spontaneously can
be delivered manuallybull Pitocin infusion started immediately post
delivery of placenta
Critical Thinkingbull
A client is admitted to the labor unit with contractions 2 to 3 minutes apart and lasting 60 to 90 seconds The client is apprehensive and vomiting This nurse understands this information to indicate that the client is most likely in what phase of labor
bull A) Active bull B) Transition bull C) Latent bull D) Second
Chapter 23Intrapartal Nursing Assessment
Initial Intrapartum AssessmentPages 608-612
bull Vital signsbull Fetal heart rate pattern fetal distressbull Contraction pattern intensity painbull Membrane status--intact ruptured nitrizine test
amniotic fluid clear meconium foul odorbull Prenatal records history of pregnancy
complications previous pregnancies and deliveries maternal health problems
bull Psychosocialfamilycultural issuesbull Labs CBC dip urine for protein glucose
ketonesbull Vaginal Exam--effacementdilationstation fetal
presentationlie Assesses LABOR PROGRESS
Intrauterine Fetal Resuscitation
bull Stop pitocinbull Reposition to left lateral Trendelenberg if neededbull Oxygen via mask at 8-10 Lminbull Increase IV fluidsbull SQ terbutaline (025 mg) if uterus not relaxingbull Vaginal exam for possible cause prolapse fetal
descent rupture abruptionbull Amnioinfusion for variable decelsbull Notify MDmidwife
Which strip shows signs thatImmediate intervention is needed Why What would you do
A
B
Experiences of Painbull Etiology bull Physiologybull Perception
bull Factors influencingAnxiety Psychological factorsExpectations Cultural factorsSupport Fetal position
Comfort and Pain Relief
bull Support from doula or coachbull Alternative therapies
bullRelaxationmassagebull Focusing and imagerybullBreathingbullHerbal preparationsaromatherapybullHypnosis
Comfort and Pain Reliefbull Pharmacological Measures
bullNarcotic analgesicsbullNubainStadolDemerol (pg 689)
bullRegional nerve blocksbullEpiduralspinal
bull Local anesthetic blocksbullPudendalperineal
Systemic AnalgesiaTable 25-3 pg 690
bull Pre-medication Assessment bull Pain level VS allergies drug dependence
(withdrawal) vaginal examprogress in labor UC pattern fetal heart rate tracing
bull Post-medication Assessmentbull VS esp RR LOC dizziness (bedpan)
sedation FHRbull Reversal agent Naloxone (Narcan)
bull Competes with narcotic for opiate receptors Used in both mom and baby (avoid with narcotic dependence)
Regional Anesthesiabull Injection of local anesthesia to block
specific nerve pathwaysbull Epiduralspinal anesthesia
bullSystemic toxicity cardiovascular collapsebullSide effects Hypotension (preload with IV
fluids) fetal distress on FHR tracing spinal HA
bullContradindications coagulation disorders low platelet count (lt 100) allergy neurologic disease aspirin use
bullNursing care Preload IV fluids (LR) monitor BP HR anesthesia level FHR foley cath maternal positioning
Epidural Anesthesia
Medication for Pain Relief Birthbull Local anesthesia
bull Pudendal nerve block (2nd stage episiotomy repair)bull Local infiltration in perineum (episiotomy repair)
bull General anesthesiabull Regional contraindicatedemergencybull Preparation hip wedge preoxygenation cricoid
pressure for intubationbull Complications fetal depression aspiration of
vomitus (Bicitra)
Local anesthesia for Episiotomy
Childbirth at Risk (Ch 26)
Complications of Labor or Delivery
Critical Thinking The client in active labor is requesting pain relief The
physician orders epidural anesthesia for the client Which of the following parameters should the nurse
be prepared to assess immediately after administration of the epidural
bull A) For headache bull B) For urinary retention bull C) The blood pressure bull D) The maternal pulse rate
Precipitous Labor amp Birthbull Labor in lt 3 hoursbull Risk factors
bull Multiparity oxytocin or amniotomy hx of precipitate labor
bull Risks for injurybull Maternal cervical vaginal amp perineal
lacerations with possible hemorrhage pain anxiety
bull Fetal Birth trauma (intracranial bleed brachial palsy) meconium-stained fluid fetal distress
bull Management close monitoring for cervical changes induction
Postterm Pregnancybull gt 42 weeksbull Maternal risks traumahemorrhage due
to larger baby uarroperative deliveryc-section
bull Fetal risks placental changes that darroxygenation to baby and uarrmortality rate oligohydramnios (uarrcord compression during labor) LGA baby (uarrbirth trauma shoulder dystocia) meconium aspiration
bull Management gt 40 wks NST BPP or modified BPP (NST amp AFI) induction
Malpresentationsbull Occiput-posterior (OP)
bull Prolonged labor back labor (sacral nerve compression) arrested dilatation descent perineal tears
bull Usually vaginal but may need C-Section if baby doesnrsquot rotate
bull Management positioning (side-lying knee-chest or hand-knees) sacral pressure during UCrsquos
bull Transverse Liebull Associated with pendulous abdomen uterine
massesfibroids congenital abnormalities of uterus hydramnios
bull Attempt External Cephalic Version if unsuccessful obligatory C-section
Malpresentations (cont)bull Breech presentation
Assessment FHT heard high on the abdomen Leopoldrsquos vaginal exam amp USbull Higher risk of anoxia from prolapsed cord traumatic injury to
the after coming head fracture of spine or arm dysfunctional labor
bull Usually delivered by C-section
External Versionbull External cephalic version (37-38 wks) abdominal
manipulation to change fetal presentationbull Contraindications multiple gestation fetal
breech is engaged in pelvis oligohydramnios nonreactive NST nuchal cord vaginal bleeding IUGR ROM
bull Risks immediate cesarean birthbull Nursing actions NPO 8 hrs NST IV line
terbutaline continuous FHR US used to guide manipulations assess for labor fetal distress O- moms need Rhogam following the procedure
MacrosomiaShoulder Dystociabull Wt gt 4500 gms (9-10 lbs)bull Associated with
bull DM Gestational DM Multiparity Postdates obesitybull Risks
bull Shoulder dystocia difficulty delivering the shoulders after head is delivered (obstetrical emergency)
bull Maternal vaginalcervical tears pp hemorrhage rupturebull Fetal compressed cord fractured clavical asphyxia amp neurologic
damage brachial plexus injury (ErbrsquosPalsy)bull SS Turtle signbull Nursing interventions McRoberts maneuvers suprapubic
pressure PP assess for uterine atonyhemorrhage trauma cerebral or neurologic damage to baby
Video youtubecomwatchv=jV6g427UMxYampfeature=related
McRoberts Maneuvers Video
Multiple Gestationbull Monozygotic (identical) twins can have 1 or 2 placentas
chorions or amnions (uarrrisk if all shared)bull Dizygotic (fraternal) twins 2 of everything
bull Dx faster than usual growth of uterus uarrAFP HCG Ultrasound
bull Risks bull Maternal SAB gestational DM HTNpreeclampsiaHELLP
hydramnios PT labor amp deliverybull Fetal Preterm birth twin-to-twin transfusion
Multiple Gestation (cont)bull Management
bull US to determine what type of twinsbull Prevention of PT laborroutine cervical measurements
(US)bull NST surveillance bull Birth depends on maternal amp fetal complications and
fetal position presentationbull Examination of placentabull Close monitoring PP for hemorrhage (atony)
Abruptio Placentaebull Premature separation of placenta from uterine wallbull SS sharp stabbing pain high in fundus heavy
bleeding (may be occult) hard board-like uterus tense painful uterus signs of shock due to blood loss Port-Wine aminotic fluid if ROM
bull Predisposing fx uarrparity adv maternal age short umbilical cord chronic HTN PIH direct trauma vasoconstriction from cocaine or cigarette use
bull Fetal distress on monitor Can progress to DIC
Abruptio Placentae (cont)bull Management
bull Emergency Immediate c-section if birth not imminent
bull Lg gauge IV bull O2 via mask fetal monitoring
maternal VS lateral positioning labs blood transfusion (have 2 units avail)
bull CBC (HampH) Fibrinogen levels platelet count PTPTT fibrin degradation products ( sx of DIC)
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
for pp hemorrhage
bull Table 26-6 pg 746 differential dx abruptioprevia
Low-lying Marginal
Partial Complete
Placenta Previas
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
Diabetes Pulmonary disease Pregnancy-induced hypertension)
bull Chorioamnionitisbull Suspected fetal problems- Intrauterine Growth
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Inductionbull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessmentbull Bishop Score- rating that determines if the cervix
is ready for induction--Pg 765bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole -Inadequate uterine relaxation between contractions lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveriesbull Forceps
bull Indications unable to push arrested descent need a quick delivery breech
bull Associated with maternalfetal birth trauma rectal sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
laborbull Elective
Placenta Factorsbull Placenta previabull Placental abruptionbull Umbilical cord prolapse
Fetal Factorsbull Breech transverse liebull Macrosomiabull Extreme low birth wtbull Fetal distressbull Fetal anomaliesbull Multiple gestation
Cesarean Birth (cont)bull Mortality
morbiditybull 4 x higher than
vaginal birth in US Most risk assoc with emergency c-section
bull Incisionbull Skin vs uterinebull Classical vs low
transverse
bull Maternal Complicationsbull Infectionbull Anesthesia reactionsbull DeepVeinThrombopheb
itisbull Bleedingbull Ureteralbladder injurybull Increase risk for
subsequent pregnancybull Placenta AcretaPrevia
Infertility
Cesarean Birthbull Pre-op CBC w platelets hold clotbull bicitraantacidbull monitor babybull Teaching pre amp post-op anesthesia recovery
breastfeedingbull Psychosocial issues
bull Fearbull Self-imageself-esteem
Post-Op Carebull Assess fundusbleeding vital signs DVTbull Antibiotics bull Pain Duramorph Breakthrough pain
meds Benadryl for itching Zofran for nausea
bull Clear liquids and advance as toleratedbull Assess for GI function Bowel sounds
Passing flatusbull Ambulation Pre-medicate teach splinting
with pillowbull Stool softener
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
multiparity excessive analgesia Afterpains wwwyoutubecomwatchv=EbItF_7KYCcampfeature=related
Fundal Assessment Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina Cervix returns to firm nongravid consistency
by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum Assessment turn pt to side in Simrsquos
position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments Constipation Give stool softeners as
ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis Superficial leg vein disease
ndash Ss tenderness in portion of vein local heat amp redness normal temperature or low-grade fever
ndash Tx local heat elevate limb bed rest analgesia elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation Engorgement day 3 or 4
ndash If breastfeeding Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
Postpartum Complications Postpartum Hemorrhage
ndash CAUSES Uterine atony lacerations retained placental fragments
Risk factorsndash uarr uterine distension multiples polyhydramnios
macrosomia fibroidsndash Trauma rapid or operative birthndash Placental problems previa accreta abruptio
retained placental fragmentsndash Atonic uterus prolonged pitocin magnesium
sulfate or labor uarr maternal age or parity uterine scar chorioamnionitis anemia prior history
ndash Inadequate blood coagulation fetal death or DIC
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
Stages of LaborSecond Stage
bull Pushing amp descent of baby (STATION)bull Full dilatation (10 cm) to birth
bull Important NOT to push until full dilationbull Assessment Urge to push Rectal
pressurebull Push only with UCrsquosbull Crowning babyrsquos head is visible at the
opening of vaginabull Cardinal movements of labor
youtubecomwatchv=Xath6kOf0NEampfeature=related youtubecomwatchv=duPxBXN4qMgampfeature=related
Mechanisms of labor A B Descent C Internal rotation D Extension E External rotation
Head Rotation during Descent
Crowning
In the hospital
Alternative settings
Crowning
Stages of Labor Third Stage
bull Placental stage from birth to delivery of placenta
bull Placental separation from uterine wall (rise of fundus sudden gush of blood lengthening of umbilical cord)
bull Entire lining of uterus shedbull Expulsion of placenta
bull Normal blood loss 300-500 mLbull If placenta does not deliver spontaneously can
be delivered manuallybull Pitocin infusion started immediately post
delivery of placenta
Critical Thinkingbull
A client is admitted to the labor unit with contractions 2 to 3 minutes apart and lasting 60 to 90 seconds The client is apprehensive and vomiting This nurse understands this information to indicate that the client is most likely in what phase of labor
bull A) Active bull B) Transition bull C) Latent bull D) Second
Chapter 23Intrapartal Nursing Assessment
Initial Intrapartum AssessmentPages 608-612
bull Vital signsbull Fetal heart rate pattern fetal distressbull Contraction pattern intensity painbull Membrane status--intact ruptured nitrizine test
amniotic fluid clear meconium foul odorbull Prenatal records history of pregnancy
complications previous pregnancies and deliveries maternal health problems
bull Psychosocialfamilycultural issuesbull Labs CBC dip urine for protein glucose
ketonesbull Vaginal Exam--effacementdilationstation fetal
presentationlie Assesses LABOR PROGRESS
Intrauterine Fetal Resuscitation
bull Stop pitocinbull Reposition to left lateral Trendelenberg if neededbull Oxygen via mask at 8-10 Lminbull Increase IV fluidsbull SQ terbutaline (025 mg) if uterus not relaxingbull Vaginal exam for possible cause prolapse fetal
descent rupture abruptionbull Amnioinfusion for variable decelsbull Notify MDmidwife
Which strip shows signs thatImmediate intervention is needed Why What would you do
A
B
Experiences of Painbull Etiology bull Physiologybull Perception
bull Factors influencingAnxiety Psychological factorsExpectations Cultural factorsSupport Fetal position
Comfort and Pain Relief
bull Support from doula or coachbull Alternative therapies
bullRelaxationmassagebull Focusing and imagerybullBreathingbullHerbal preparationsaromatherapybullHypnosis
Comfort and Pain Reliefbull Pharmacological Measures
bullNarcotic analgesicsbullNubainStadolDemerol (pg 689)
bullRegional nerve blocksbullEpiduralspinal
bull Local anesthetic blocksbullPudendalperineal
Systemic AnalgesiaTable 25-3 pg 690
bull Pre-medication Assessment bull Pain level VS allergies drug dependence
(withdrawal) vaginal examprogress in labor UC pattern fetal heart rate tracing
bull Post-medication Assessmentbull VS esp RR LOC dizziness (bedpan)
sedation FHRbull Reversal agent Naloxone (Narcan)
bull Competes with narcotic for opiate receptors Used in both mom and baby (avoid with narcotic dependence)
Regional Anesthesiabull Injection of local anesthesia to block
specific nerve pathwaysbull Epiduralspinal anesthesia
bullSystemic toxicity cardiovascular collapsebullSide effects Hypotension (preload with IV
fluids) fetal distress on FHR tracing spinal HA
bullContradindications coagulation disorders low platelet count (lt 100) allergy neurologic disease aspirin use
bullNursing care Preload IV fluids (LR) monitor BP HR anesthesia level FHR foley cath maternal positioning
Epidural Anesthesia
Medication for Pain Relief Birthbull Local anesthesia
bull Pudendal nerve block (2nd stage episiotomy repair)bull Local infiltration in perineum (episiotomy repair)
bull General anesthesiabull Regional contraindicatedemergencybull Preparation hip wedge preoxygenation cricoid
pressure for intubationbull Complications fetal depression aspiration of
vomitus (Bicitra)
Local anesthesia for Episiotomy
Childbirth at Risk (Ch 26)
Complications of Labor or Delivery
Critical Thinking The client in active labor is requesting pain relief The
physician orders epidural anesthesia for the client Which of the following parameters should the nurse
be prepared to assess immediately after administration of the epidural
bull A) For headache bull B) For urinary retention bull C) The blood pressure bull D) The maternal pulse rate
Precipitous Labor amp Birthbull Labor in lt 3 hoursbull Risk factors
bull Multiparity oxytocin or amniotomy hx of precipitate labor
bull Risks for injurybull Maternal cervical vaginal amp perineal
lacerations with possible hemorrhage pain anxiety
bull Fetal Birth trauma (intracranial bleed brachial palsy) meconium-stained fluid fetal distress
bull Management close monitoring for cervical changes induction
Postterm Pregnancybull gt 42 weeksbull Maternal risks traumahemorrhage due
to larger baby uarroperative deliveryc-section
bull Fetal risks placental changes that darroxygenation to baby and uarrmortality rate oligohydramnios (uarrcord compression during labor) LGA baby (uarrbirth trauma shoulder dystocia) meconium aspiration
bull Management gt 40 wks NST BPP or modified BPP (NST amp AFI) induction
Malpresentationsbull Occiput-posterior (OP)
bull Prolonged labor back labor (sacral nerve compression) arrested dilatation descent perineal tears
bull Usually vaginal but may need C-Section if baby doesnrsquot rotate
bull Management positioning (side-lying knee-chest or hand-knees) sacral pressure during UCrsquos
bull Transverse Liebull Associated with pendulous abdomen uterine
massesfibroids congenital abnormalities of uterus hydramnios
bull Attempt External Cephalic Version if unsuccessful obligatory C-section
Malpresentations (cont)bull Breech presentation
Assessment FHT heard high on the abdomen Leopoldrsquos vaginal exam amp USbull Higher risk of anoxia from prolapsed cord traumatic injury to
the after coming head fracture of spine or arm dysfunctional labor
bull Usually delivered by C-section
External Versionbull External cephalic version (37-38 wks) abdominal
manipulation to change fetal presentationbull Contraindications multiple gestation fetal
breech is engaged in pelvis oligohydramnios nonreactive NST nuchal cord vaginal bleeding IUGR ROM
bull Risks immediate cesarean birthbull Nursing actions NPO 8 hrs NST IV line
terbutaline continuous FHR US used to guide manipulations assess for labor fetal distress O- moms need Rhogam following the procedure
MacrosomiaShoulder Dystociabull Wt gt 4500 gms (9-10 lbs)bull Associated with
bull DM Gestational DM Multiparity Postdates obesitybull Risks
bull Shoulder dystocia difficulty delivering the shoulders after head is delivered (obstetrical emergency)
bull Maternal vaginalcervical tears pp hemorrhage rupturebull Fetal compressed cord fractured clavical asphyxia amp neurologic
damage brachial plexus injury (ErbrsquosPalsy)bull SS Turtle signbull Nursing interventions McRoberts maneuvers suprapubic
pressure PP assess for uterine atonyhemorrhage trauma cerebral or neurologic damage to baby
Video youtubecomwatchv=jV6g427UMxYampfeature=related
McRoberts Maneuvers Video
Multiple Gestationbull Monozygotic (identical) twins can have 1 or 2 placentas
chorions or amnions (uarrrisk if all shared)bull Dizygotic (fraternal) twins 2 of everything
bull Dx faster than usual growth of uterus uarrAFP HCG Ultrasound
bull Risks bull Maternal SAB gestational DM HTNpreeclampsiaHELLP
hydramnios PT labor amp deliverybull Fetal Preterm birth twin-to-twin transfusion
Multiple Gestation (cont)bull Management
bull US to determine what type of twinsbull Prevention of PT laborroutine cervical measurements
(US)bull NST surveillance bull Birth depends on maternal amp fetal complications and
fetal position presentationbull Examination of placentabull Close monitoring PP for hemorrhage (atony)
Abruptio Placentaebull Premature separation of placenta from uterine wallbull SS sharp stabbing pain high in fundus heavy
bleeding (may be occult) hard board-like uterus tense painful uterus signs of shock due to blood loss Port-Wine aminotic fluid if ROM
bull Predisposing fx uarrparity adv maternal age short umbilical cord chronic HTN PIH direct trauma vasoconstriction from cocaine or cigarette use
bull Fetal distress on monitor Can progress to DIC
Abruptio Placentae (cont)bull Management
bull Emergency Immediate c-section if birth not imminent
bull Lg gauge IV bull O2 via mask fetal monitoring
maternal VS lateral positioning labs blood transfusion (have 2 units avail)
bull CBC (HampH) Fibrinogen levels platelet count PTPTT fibrin degradation products ( sx of DIC)
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
for pp hemorrhage
bull Table 26-6 pg 746 differential dx abruptioprevia
Low-lying Marginal
Partial Complete
Placenta Previas
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
Diabetes Pulmonary disease Pregnancy-induced hypertension)
bull Chorioamnionitisbull Suspected fetal problems- Intrauterine Growth
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Inductionbull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessmentbull Bishop Score- rating that determines if the cervix
is ready for induction--Pg 765bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole -Inadequate uterine relaxation between contractions lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveriesbull Forceps
bull Indications unable to push arrested descent need a quick delivery breech
bull Associated with maternalfetal birth trauma rectal sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
laborbull Elective
Placenta Factorsbull Placenta previabull Placental abruptionbull Umbilical cord prolapse
Fetal Factorsbull Breech transverse liebull Macrosomiabull Extreme low birth wtbull Fetal distressbull Fetal anomaliesbull Multiple gestation
Cesarean Birth (cont)bull Mortality
morbiditybull 4 x higher than
vaginal birth in US Most risk assoc with emergency c-section
bull Incisionbull Skin vs uterinebull Classical vs low
transverse
bull Maternal Complicationsbull Infectionbull Anesthesia reactionsbull DeepVeinThrombopheb
itisbull Bleedingbull Ureteralbladder injurybull Increase risk for
subsequent pregnancybull Placenta AcretaPrevia
Infertility
Cesarean Birthbull Pre-op CBC w platelets hold clotbull bicitraantacidbull monitor babybull Teaching pre amp post-op anesthesia recovery
breastfeedingbull Psychosocial issues
bull Fearbull Self-imageself-esteem
Post-Op Carebull Assess fundusbleeding vital signs DVTbull Antibiotics bull Pain Duramorph Breakthrough pain
meds Benadryl for itching Zofran for nausea
bull Clear liquids and advance as toleratedbull Assess for GI function Bowel sounds
Passing flatusbull Ambulation Pre-medicate teach splinting
with pillowbull Stool softener
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
multiparity excessive analgesia Afterpains wwwyoutubecomwatchv=EbItF_7KYCcampfeature=related
Fundal Assessment Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina Cervix returns to firm nongravid consistency
by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum Assessment turn pt to side in Simrsquos
position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments Constipation Give stool softeners as
ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis Superficial leg vein disease
ndash Ss tenderness in portion of vein local heat amp redness normal temperature or low-grade fever
ndash Tx local heat elevate limb bed rest analgesia elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation Engorgement day 3 or 4
ndash If breastfeeding Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
Postpartum Complications Postpartum Hemorrhage
ndash CAUSES Uterine atony lacerations retained placental fragments
Risk factorsndash uarr uterine distension multiples polyhydramnios
macrosomia fibroidsndash Trauma rapid or operative birthndash Placental problems previa accreta abruptio
retained placental fragmentsndash Atonic uterus prolonged pitocin magnesium
sulfate or labor uarr maternal age or parity uterine scar chorioamnionitis anemia prior history
ndash Inadequate blood coagulation fetal death or DIC
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
Mechanisms of labor A B Descent C Internal rotation D Extension E External rotation
Head Rotation during Descent
Crowning
In the hospital
Alternative settings
Crowning
Stages of Labor Third Stage
bull Placental stage from birth to delivery of placenta
bull Placental separation from uterine wall (rise of fundus sudden gush of blood lengthening of umbilical cord)
bull Entire lining of uterus shedbull Expulsion of placenta
bull Normal blood loss 300-500 mLbull If placenta does not deliver spontaneously can
be delivered manuallybull Pitocin infusion started immediately post
delivery of placenta
Critical Thinkingbull
A client is admitted to the labor unit with contractions 2 to 3 minutes apart and lasting 60 to 90 seconds The client is apprehensive and vomiting This nurse understands this information to indicate that the client is most likely in what phase of labor
bull A) Active bull B) Transition bull C) Latent bull D) Second
Chapter 23Intrapartal Nursing Assessment
Initial Intrapartum AssessmentPages 608-612
bull Vital signsbull Fetal heart rate pattern fetal distressbull Contraction pattern intensity painbull Membrane status--intact ruptured nitrizine test
amniotic fluid clear meconium foul odorbull Prenatal records history of pregnancy
complications previous pregnancies and deliveries maternal health problems
bull Psychosocialfamilycultural issuesbull Labs CBC dip urine for protein glucose
ketonesbull Vaginal Exam--effacementdilationstation fetal
presentationlie Assesses LABOR PROGRESS
Intrauterine Fetal Resuscitation
bull Stop pitocinbull Reposition to left lateral Trendelenberg if neededbull Oxygen via mask at 8-10 Lminbull Increase IV fluidsbull SQ terbutaline (025 mg) if uterus not relaxingbull Vaginal exam for possible cause prolapse fetal
descent rupture abruptionbull Amnioinfusion for variable decelsbull Notify MDmidwife
Which strip shows signs thatImmediate intervention is needed Why What would you do
A
B
Experiences of Painbull Etiology bull Physiologybull Perception
bull Factors influencingAnxiety Psychological factorsExpectations Cultural factorsSupport Fetal position
Comfort and Pain Relief
bull Support from doula or coachbull Alternative therapies
bullRelaxationmassagebull Focusing and imagerybullBreathingbullHerbal preparationsaromatherapybullHypnosis
Comfort and Pain Reliefbull Pharmacological Measures
bullNarcotic analgesicsbullNubainStadolDemerol (pg 689)
bullRegional nerve blocksbullEpiduralspinal
bull Local anesthetic blocksbullPudendalperineal
Systemic AnalgesiaTable 25-3 pg 690
bull Pre-medication Assessment bull Pain level VS allergies drug dependence
(withdrawal) vaginal examprogress in labor UC pattern fetal heart rate tracing
bull Post-medication Assessmentbull VS esp RR LOC dizziness (bedpan)
sedation FHRbull Reversal agent Naloxone (Narcan)
bull Competes with narcotic for opiate receptors Used in both mom and baby (avoid with narcotic dependence)
Regional Anesthesiabull Injection of local anesthesia to block
specific nerve pathwaysbull Epiduralspinal anesthesia
bullSystemic toxicity cardiovascular collapsebullSide effects Hypotension (preload with IV
fluids) fetal distress on FHR tracing spinal HA
bullContradindications coagulation disorders low platelet count (lt 100) allergy neurologic disease aspirin use
bullNursing care Preload IV fluids (LR) monitor BP HR anesthesia level FHR foley cath maternal positioning
Epidural Anesthesia
Medication for Pain Relief Birthbull Local anesthesia
bull Pudendal nerve block (2nd stage episiotomy repair)bull Local infiltration in perineum (episiotomy repair)
bull General anesthesiabull Regional contraindicatedemergencybull Preparation hip wedge preoxygenation cricoid
pressure for intubationbull Complications fetal depression aspiration of
vomitus (Bicitra)
Local anesthesia for Episiotomy
Childbirth at Risk (Ch 26)
Complications of Labor or Delivery
Critical Thinking The client in active labor is requesting pain relief The
physician orders epidural anesthesia for the client Which of the following parameters should the nurse
be prepared to assess immediately after administration of the epidural
bull A) For headache bull B) For urinary retention bull C) The blood pressure bull D) The maternal pulse rate
Precipitous Labor amp Birthbull Labor in lt 3 hoursbull Risk factors
bull Multiparity oxytocin or amniotomy hx of precipitate labor
bull Risks for injurybull Maternal cervical vaginal amp perineal
lacerations with possible hemorrhage pain anxiety
bull Fetal Birth trauma (intracranial bleed brachial palsy) meconium-stained fluid fetal distress
bull Management close monitoring for cervical changes induction
Postterm Pregnancybull gt 42 weeksbull Maternal risks traumahemorrhage due
to larger baby uarroperative deliveryc-section
bull Fetal risks placental changes that darroxygenation to baby and uarrmortality rate oligohydramnios (uarrcord compression during labor) LGA baby (uarrbirth trauma shoulder dystocia) meconium aspiration
bull Management gt 40 wks NST BPP or modified BPP (NST amp AFI) induction
Malpresentationsbull Occiput-posterior (OP)
bull Prolonged labor back labor (sacral nerve compression) arrested dilatation descent perineal tears
bull Usually vaginal but may need C-Section if baby doesnrsquot rotate
bull Management positioning (side-lying knee-chest or hand-knees) sacral pressure during UCrsquos
bull Transverse Liebull Associated with pendulous abdomen uterine
massesfibroids congenital abnormalities of uterus hydramnios
bull Attempt External Cephalic Version if unsuccessful obligatory C-section
Malpresentations (cont)bull Breech presentation
Assessment FHT heard high on the abdomen Leopoldrsquos vaginal exam amp USbull Higher risk of anoxia from prolapsed cord traumatic injury to
the after coming head fracture of spine or arm dysfunctional labor
bull Usually delivered by C-section
External Versionbull External cephalic version (37-38 wks) abdominal
manipulation to change fetal presentationbull Contraindications multiple gestation fetal
breech is engaged in pelvis oligohydramnios nonreactive NST nuchal cord vaginal bleeding IUGR ROM
bull Risks immediate cesarean birthbull Nursing actions NPO 8 hrs NST IV line
terbutaline continuous FHR US used to guide manipulations assess for labor fetal distress O- moms need Rhogam following the procedure
MacrosomiaShoulder Dystociabull Wt gt 4500 gms (9-10 lbs)bull Associated with
bull DM Gestational DM Multiparity Postdates obesitybull Risks
bull Shoulder dystocia difficulty delivering the shoulders after head is delivered (obstetrical emergency)
bull Maternal vaginalcervical tears pp hemorrhage rupturebull Fetal compressed cord fractured clavical asphyxia amp neurologic
damage brachial plexus injury (ErbrsquosPalsy)bull SS Turtle signbull Nursing interventions McRoberts maneuvers suprapubic
pressure PP assess for uterine atonyhemorrhage trauma cerebral or neurologic damage to baby
Video youtubecomwatchv=jV6g427UMxYampfeature=related
McRoberts Maneuvers Video
Multiple Gestationbull Monozygotic (identical) twins can have 1 or 2 placentas
chorions or amnions (uarrrisk if all shared)bull Dizygotic (fraternal) twins 2 of everything
bull Dx faster than usual growth of uterus uarrAFP HCG Ultrasound
bull Risks bull Maternal SAB gestational DM HTNpreeclampsiaHELLP
hydramnios PT labor amp deliverybull Fetal Preterm birth twin-to-twin transfusion
Multiple Gestation (cont)bull Management
bull US to determine what type of twinsbull Prevention of PT laborroutine cervical measurements
(US)bull NST surveillance bull Birth depends on maternal amp fetal complications and
fetal position presentationbull Examination of placentabull Close monitoring PP for hemorrhage (atony)
Abruptio Placentaebull Premature separation of placenta from uterine wallbull SS sharp stabbing pain high in fundus heavy
bleeding (may be occult) hard board-like uterus tense painful uterus signs of shock due to blood loss Port-Wine aminotic fluid if ROM
bull Predisposing fx uarrparity adv maternal age short umbilical cord chronic HTN PIH direct trauma vasoconstriction from cocaine or cigarette use
bull Fetal distress on monitor Can progress to DIC
Abruptio Placentae (cont)bull Management
bull Emergency Immediate c-section if birth not imminent
bull Lg gauge IV bull O2 via mask fetal monitoring
maternal VS lateral positioning labs blood transfusion (have 2 units avail)
bull CBC (HampH) Fibrinogen levels platelet count PTPTT fibrin degradation products ( sx of DIC)
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
for pp hemorrhage
bull Table 26-6 pg 746 differential dx abruptioprevia
Low-lying Marginal
Partial Complete
Placenta Previas
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
Diabetes Pulmonary disease Pregnancy-induced hypertension)
bull Chorioamnionitisbull Suspected fetal problems- Intrauterine Growth
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Inductionbull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessmentbull Bishop Score- rating that determines if the cervix
is ready for induction--Pg 765bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole -Inadequate uterine relaxation between contractions lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveriesbull Forceps
bull Indications unable to push arrested descent need a quick delivery breech
bull Associated with maternalfetal birth trauma rectal sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
laborbull Elective
Placenta Factorsbull Placenta previabull Placental abruptionbull Umbilical cord prolapse
Fetal Factorsbull Breech transverse liebull Macrosomiabull Extreme low birth wtbull Fetal distressbull Fetal anomaliesbull Multiple gestation
Cesarean Birth (cont)bull Mortality
morbiditybull 4 x higher than
vaginal birth in US Most risk assoc with emergency c-section
bull Incisionbull Skin vs uterinebull Classical vs low
transverse
bull Maternal Complicationsbull Infectionbull Anesthesia reactionsbull DeepVeinThrombopheb
itisbull Bleedingbull Ureteralbladder injurybull Increase risk for
subsequent pregnancybull Placenta AcretaPrevia
Infertility
Cesarean Birthbull Pre-op CBC w platelets hold clotbull bicitraantacidbull monitor babybull Teaching pre amp post-op anesthesia recovery
breastfeedingbull Psychosocial issues
bull Fearbull Self-imageself-esteem
Post-Op Carebull Assess fundusbleeding vital signs DVTbull Antibiotics bull Pain Duramorph Breakthrough pain
meds Benadryl for itching Zofran for nausea
bull Clear liquids and advance as toleratedbull Assess for GI function Bowel sounds
Passing flatusbull Ambulation Pre-medicate teach splinting
with pillowbull Stool softener
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
multiparity excessive analgesia Afterpains wwwyoutubecomwatchv=EbItF_7KYCcampfeature=related
Fundal Assessment Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina Cervix returns to firm nongravid consistency
by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum Assessment turn pt to side in Simrsquos
position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments Constipation Give stool softeners as
ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis Superficial leg vein disease
ndash Ss tenderness in portion of vein local heat amp redness normal temperature or low-grade fever
ndash Tx local heat elevate limb bed rest analgesia elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation Engorgement day 3 or 4
ndash If breastfeeding Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
Postpartum Complications Postpartum Hemorrhage
ndash CAUSES Uterine atony lacerations retained placental fragments
Risk factorsndash uarr uterine distension multiples polyhydramnios
macrosomia fibroidsndash Trauma rapid or operative birthndash Placental problems previa accreta abruptio
retained placental fragmentsndash Atonic uterus prolonged pitocin magnesium
sulfate or labor uarr maternal age or parity uterine scar chorioamnionitis anemia prior history
ndash Inadequate blood coagulation fetal death or DIC
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
Head Rotation during Descent
Crowning
In the hospital
Alternative settings
Crowning
Stages of Labor Third Stage
bull Placental stage from birth to delivery of placenta
bull Placental separation from uterine wall (rise of fundus sudden gush of blood lengthening of umbilical cord)
bull Entire lining of uterus shedbull Expulsion of placenta
bull Normal blood loss 300-500 mLbull If placenta does not deliver spontaneously can
be delivered manuallybull Pitocin infusion started immediately post
delivery of placenta
Critical Thinkingbull
A client is admitted to the labor unit with contractions 2 to 3 minutes apart and lasting 60 to 90 seconds The client is apprehensive and vomiting This nurse understands this information to indicate that the client is most likely in what phase of labor
bull A) Active bull B) Transition bull C) Latent bull D) Second
Chapter 23Intrapartal Nursing Assessment
Initial Intrapartum AssessmentPages 608-612
bull Vital signsbull Fetal heart rate pattern fetal distressbull Contraction pattern intensity painbull Membrane status--intact ruptured nitrizine test
amniotic fluid clear meconium foul odorbull Prenatal records history of pregnancy
complications previous pregnancies and deliveries maternal health problems
bull Psychosocialfamilycultural issuesbull Labs CBC dip urine for protein glucose
ketonesbull Vaginal Exam--effacementdilationstation fetal
presentationlie Assesses LABOR PROGRESS
Intrauterine Fetal Resuscitation
bull Stop pitocinbull Reposition to left lateral Trendelenberg if neededbull Oxygen via mask at 8-10 Lminbull Increase IV fluidsbull SQ terbutaline (025 mg) if uterus not relaxingbull Vaginal exam for possible cause prolapse fetal
descent rupture abruptionbull Amnioinfusion for variable decelsbull Notify MDmidwife
Which strip shows signs thatImmediate intervention is needed Why What would you do
A
B
Experiences of Painbull Etiology bull Physiologybull Perception
bull Factors influencingAnxiety Psychological factorsExpectations Cultural factorsSupport Fetal position
Comfort and Pain Relief
bull Support from doula or coachbull Alternative therapies
bullRelaxationmassagebull Focusing and imagerybullBreathingbullHerbal preparationsaromatherapybullHypnosis
Comfort and Pain Reliefbull Pharmacological Measures
bullNarcotic analgesicsbullNubainStadolDemerol (pg 689)
bullRegional nerve blocksbullEpiduralspinal
bull Local anesthetic blocksbullPudendalperineal
Systemic AnalgesiaTable 25-3 pg 690
bull Pre-medication Assessment bull Pain level VS allergies drug dependence
(withdrawal) vaginal examprogress in labor UC pattern fetal heart rate tracing
bull Post-medication Assessmentbull VS esp RR LOC dizziness (bedpan)
sedation FHRbull Reversal agent Naloxone (Narcan)
bull Competes with narcotic for opiate receptors Used in both mom and baby (avoid with narcotic dependence)
Regional Anesthesiabull Injection of local anesthesia to block
specific nerve pathwaysbull Epiduralspinal anesthesia
bullSystemic toxicity cardiovascular collapsebullSide effects Hypotension (preload with IV
fluids) fetal distress on FHR tracing spinal HA
bullContradindications coagulation disorders low platelet count (lt 100) allergy neurologic disease aspirin use
bullNursing care Preload IV fluids (LR) monitor BP HR anesthesia level FHR foley cath maternal positioning
Epidural Anesthesia
Medication for Pain Relief Birthbull Local anesthesia
bull Pudendal nerve block (2nd stage episiotomy repair)bull Local infiltration in perineum (episiotomy repair)
bull General anesthesiabull Regional contraindicatedemergencybull Preparation hip wedge preoxygenation cricoid
pressure for intubationbull Complications fetal depression aspiration of
vomitus (Bicitra)
Local anesthesia for Episiotomy
Childbirth at Risk (Ch 26)
Complications of Labor or Delivery
Critical Thinking The client in active labor is requesting pain relief The
physician orders epidural anesthesia for the client Which of the following parameters should the nurse
be prepared to assess immediately after administration of the epidural
bull A) For headache bull B) For urinary retention bull C) The blood pressure bull D) The maternal pulse rate
Precipitous Labor amp Birthbull Labor in lt 3 hoursbull Risk factors
bull Multiparity oxytocin or amniotomy hx of precipitate labor
bull Risks for injurybull Maternal cervical vaginal amp perineal
lacerations with possible hemorrhage pain anxiety
bull Fetal Birth trauma (intracranial bleed brachial palsy) meconium-stained fluid fetal distress
bull Management close monitoring for cervical changes induction
Postterm Pregnancybull gt 42 weeksbull Maternal risks traumahemorrhage due
to larger baby uarroperative deliveryc-section
bull Fetal risks placental changes that darroxygenation to baby and uarrmortality rate oligohydramnios (uarrcord compression during labor) LGA baby (uarrbirth trauma shoulder dystocia) meconium aspiration
bull Management gt 40 wks NST BPP or modified BPP (NST amp AFI) induction
Malpresentationsbull Occiput-posterior (OP)
bull Prolonged labor back labor (sacral nerve compression) arrested dilatation descent perineal tears
bull Usually vaginal but may need C-Section if baby doesnrsquot rotate
bull Management positioning (side-lying knee-chest or hand-knees) sacral pressure during UCrsquos
bull Transverse Liebull Associated with pendulous abdomen uterine
massesfibroids congenital abnormalities of uterus hydramnios
bull Attempt External Cephalic Version if unsuccessful obligatory C-section
Malpresentations (cont)bull Breech presentation
Assessment FHT heard high on the abdomen Leopoldrsquos vaginal exam amp USbull Higher risk of anoxia from prolapsed cord traumatic injury to
the after coming head fracture of spine or arm dysfunctional labor
bull Usually delivered by C-section
External Versionbull External cephalic version (37-38 wks) abdominal
manipulation to change fetal presentationbull Contraindications multiple gestation fetal
breech is engaged in pelvis oligohydramnios nonreactive NST nuchal cord vaginal bleeding IUGR ROM
bull Risks immediate cesarean birthbull Nursing actions NPO 8 hrs NST IV line
terbutaline continuous FHR US used to guide manipulations assess for labor fetal distress O- moms need Rhogam following the procedure
MacrosomiaShoulder Dystociabull Wt gt 4500 gms (9-10 lbs)bull Associated with
bull DM Gestational DM Multiparity Postdates obesitybull Risks
bull Shoulder dystocia difficulty delivering the shoulders after head is delivered (obstetrical emergency)
bull Maternal vaginalcervical tears pp hemorrhage rupturebull Fetal compressed cord fractured clavical asphyxia amp neurologic
damage brachial plexus injury (ErbrsquosPalsy)bull SS Turtle signbull Nursing interventions McRoberts maneuvers suprapubic
pressure PP assess for uterine atonyhemorrhage trauma cerebral or neurologic damage to baby
Video youtubecomwatchv=jV6g427UMxYampfeature=related
McRoberts Maneuvers Video
Multiple Gestationbull Monozygotic (identical) twins can have 1 or 2 placentas
chorions or amnions (uarrrisk if all shared)bull Dizygotic (fraternal) twins 2 of everything
bull Dx faster than usual growth of uterus uarrAFP HCG Ultrasound
bull Risks bull Maternal SAB gestational DM HTNpreeclampsiaHELLP
hydramnios PT labor amp deliverybull Fetal Preterm birth twin-to-twin transfusion
Multiple Gestation (cont)bull Management
bull US to determine what type of twinsbull Prevention of PT laborroutine cervical measurements
(US)bull NST surveillance bull Birth depends on maternal amp fetal complications and
fetal position presentationbull Examination of placentabull Close monitoring PP for hemorrhage (atony)
Abruptio Placentaebull Premature separation of placenta from uterine wallbull SS sharp stabbing pain high in fundus heavy
bleeding (may be occult) hard board-like uterus tense painful uterus signs of shock due to blood loss Port-Wine aminotic fluid if ROM
bull Predisposing fx uarrparity adv maternal age short umbilical cord chronic HTN PIH direct trauma vasoconstriction from cocaine or cigarette use
bull Fetal distress on monitor Can progress to DIC
Abruptio Placentae (cont)bull Management
bull Emergency Immediate c-section if birth not imminent
bull Lg gauge IV bull O2 via mask fetal monitoring
maternal VS lateral positioning labs blood transfusion (have 2 units avail)
bull CBC (HampH) Fibrinogen levels platelet count PTPTT fibrin degradation products ( sx of DIC)
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
for pp hemorrhage
bull Table 26-6 pg 746 differential dx abruptioprevia
Low-lying Marginal
Partial Complete
Placenta Previas
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
Diabetes Pulmonary disease Pregnancy-induced hypertension)
bull Chorioamnionitisbull Suspected fetal problems- Intrauterine Growth
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Inductionbull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessmentbull Bishop Score- rating that determines if the cervix
is ready for induction--Pg 765bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole -Inadequate uterine relaxation between contractions lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveriesbull Forceps
bull Indications unable to push arrested descent need a quick delivery breech
bull Associated with maternalfetal birth trauma rectal sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
laborbull Elective
Placenta Factorsbull Placenta previabull Placental abruptionbull Umbilical cord prolapse
Fetal Factorsbull Breech transverse liebull Macrosomiabull Extreme low birth wtbull Fetal distressbull Fetal anomaliesbull Multiple gestation
Cesarean Birth (cont)bull Mortality
morbiditybull 4 x higher than
vaginal birth in US Most risk assoc with emergency c-section
bull Incisionbull Skin vs uterinebull Classical vs low
transverse
bull Maternal Complicationsbull Infectionbull Anesthesia reactionsbull DeepVeinThrombopheb
itisbull Bleedingbull Ureteralbladder injurybull Increase risk for
subsequent pregnancybull Placenta AcretaPrevia
Infertility
Cesarean Birthbull Pre-op CBC w platelets hold clotbull bicitraantacidbull monitor babybull Teaching pre amp post-op anesthesia recovery
breastfeedingbull Psychosocial issues
bull Fearbull Self-imageself-esteem
Post-Op Carebull Assess fundusbleeding vital signs DVTbull Antibiotics bull Pain Duramorph Breakthrough pain
meds Benadryl for itching Zofran for nausea
bull Clear liquids and advance as toleratedbull Assess for GI function Bowel sounds
Passing flatusbull Ambulation Pre-medicate teach splinting
with pillowbull Stool softener
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
multiparity excessive analgesia Afterpains wwwyoutubecomwatchv=EbItF_7KYCcampfeature=related
Fundal Assessment Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina Cervix returns to firm nongravid consistency
by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum Assessment turn pt to side in Simrsquos
position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments Constipation Give stool softeners as
ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis Superficial leg vein disease
ndash Ss tenderness in portion of vein local heat amp redness normal temperature or low-grade fever
ndash Tx local heat elevate limb bed rest analgesia elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation Engorgement day 3 or 4
ndash If breastfeeding Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
Postpartum Complications Postpartum Hemorrhage
ndash CAUSES Uterine atony lacerations retained placental fragments
Risk factorsndash uarr uterine distension multiples polyhydramnios
macrosomia fibroidsndash Trauma rapid or operative birthndash Placental problems previa accreta abruptio
retained placental fragmentsndash Atonic uterus prolonged pitocin magnesium
sulfate or labor uarr maternal age or parity uterine scar chorioamnionitis anemia prior history
ndash Inadequate blood coagulation fetal death or DIC
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
Crowning
In the hospital
Alternative settings
Crowning
Stages of Labor Third Stage
bull Placental stage from birth to delivery of placenta
bull Placental separation from uterine wall (rise of fundus sudden gush of blood lengthening of umbilical cord)
bull Entire lining of uterus shedbull Expulsion of placenta
bull Normal blood loss 300-500 mLbull If placenta does not deliver spontaneously can
be delivered manuallybull Pitocin infusion started immediately post
delivery of placenta
Critical Thinkingbull
A client is admitted to the labor unit with contractions 2 to 3 minutes apart and lasting 60 to 90 seconds The client is apprehensive and vomiting This nurse understands this information to indicate that the client is most likely in what phase of labor
bull A) Active bull B) Transition bull C) Latent bull D) Second
Chapter 23Intrapartal Nursing Assessment
Initial Intrapartum AssessmentPages 608-612
bull Vital signsbull Fetal heart rate pattern fetal distressbull Contraction pattern intensity painbull Membrane status--intact ruptured nitrizine test
amniotic fluid clear meconium foul odorbull Prenatal records history of pregnancy
complications previous pregnancies and deliveries maternal health problems
bull Psychosocialfamilycultural issuesbull Labs CBC dip urine for protein glucose
ketonesbull Vaginal Exam--effacementdilationstation fetal
presentationlie Assesses LABOR PROGRESS
Intrauterine Fetal Resuscitation
bull Stop pitocinbull Reposition to left lateral Trendelenberg if neededbull Oxygen via mask at 8-10 Lminbull Increase IV fluidsbull SQ terbutaline (025 mg) if uterus not relaxingbull Vaginal exam for possible cause prolapse fetal
descent rupture abruptionbull Amnioinfusion for variable decelsbull Notify MDmidwife
Which strip shows signs thatImmediate intervention is needed Why What would you do
A
B
Experiences of Painbull Etiology bull Physiologybull Perception
bull Factors influencingAnxiety Psychological factorsExpectations Cultural factorsSupport Fetal position
Comfort and Pain Relief
bull Support from doula or coachbull Alternative therapies
bullRelaxationmassagebull Focusing and imagerybullBreathingbullHerbal preparationsaromatherapybullHypnosis
Comfort and Pain Reliefbull Pharmacological Measures
bullNarcotic analgesicsbullNubainStadolDemerol (pg 689)
bullRegional nerve blocksbullEpiduralspinal
bull Local anesthetic blocksbullPudendalperineal
Systemic AnalgesiaTable 25-3 pg 690
bull Pre-medication Assessment bull Pain level VS allergies drug dependence
(withdrawal) vaginal examprogress in labor UC pattern fetal heart rate tracing
bull Post-medication Assessmentbull VS esp RR LOC dizziness (bedpan)
sedation FHRbull Reversal agent Naloxone (Narcan)
bull Competes with narcotic for opiate receptors Used in both mom and baby (avoid with narcotic dependence)
Regional Anesthesiabull Injection of local anesthesia to block
specific nerve pathwaysbull Epiduralspinal anesthesia
bullSystemic toxicity cardiovascular collapsebullSide effects Hypotension (preload with IV
fluids) fetal distress on FHR tracing spinal HA
bullContradindications coagulation disorders low platelet count (lt 100) allergy neurologic disease aspirin use
bullNursing care Preload IV fluids (LR) monitor BP HR anesthesia level FHR foley cath maternal positioning
Epidural Anesthesia
Medication for Pain Relief Birthbull Local anesthesia
bull Pudendal nerve block (2nd stage episiotomy repair)bull Local infiltration in perineum (episiotomy repair)
bull General anesthesiabull Regional contraindicatedemergencybull Preparation hip wedge preoxygenation cricoid
pressure for intubationbull Complications fetal depression aspiration of
vomitus (Bicitra)
Local anesthesia for Episiotomy
Childbirth at Risk (Ch 26)
Complications of Labor or Delivery
Critical Thinking The client in active labor is requesting pain relief The
physician orders epidural anesthesia for the client Which of the following parameters should the nurse
be prepared to assess immediately after administration of the epidural
bull A) For headache bull B) For urinary retention bull C) The blood pressure bull D) The maternal pulse rate
Precipitous Labor amp Birthbull Labor in lt 3 hoursbull Risk factors
bull Multiparity oxytocin or amniotomy hx of precipitate labor
bull Risks for injurybull Maternal cervical vaginal amp perineal
lacerations with possible hemorrhage pain anxiety
bull Fetal Birth trauma (intracranial bleed brachial palsy) meconium-stained fluid fetal distress
bull Management close monitoring for cervical changes induction
Postterm Pregnancybull gt 42 weeksbull Maternal risks traumahemorrhage due
to larger baby uarroperative deliveryc-section
bull Fetal risks placental changes that darroxygenation to baby and uarrmortality rate oligohydramnios (uarrcord compression during labor) LGA baby (uarrbirth trauma shoulder dystocia) meconium aspiration
bull Management gt 40 wks NST BPP or modified BPP (NST amp AFI) induction
Malpresentationsbull Occiput-posterior (OP)
bull Prolonged labor back labor (sacral nerve compression) arrested dilatation descent perineal tears
bull Usually vaginal but may need C-Section if baby doesnrsquot rotate
bull Management positioning (side-lying knee-chest or hand-knees) sacral pressure during UCrsquos
bull Transverse Liebull Associated with pendulous abdomen uterine
massesfibroids congenital abnormalities of uterus hydramnios
bull Attempt External Cephalic Version if unsuccessful obligatory C-section
Malpresentations (cont)bull Breech presentation
Assessment FHT heard high on the abdomen Leopoldrsquos vaginal exam amp USbull Higher risk of anoxia from prolapsed cord traumatic injury to
the after coming head fracture of spine or arm dysfunctional labor
bull Usually delivered by C-section
External Versionbull External cephalic version (37-38 wks) abdominal
manipulation to change fetal presentationbull Contraindications multiple gestation fetal
breech is engaged in pelvis oligohydramnios nonreactive NST nuchal cord vaginal bleeding IUGR ROM
bull Risks immediate cesarean birthbull Nursing actions NPO 8 hrs NST IV line
terbutaline continuous FHR US used to guide manipulations assess for labor fetal distress O- moms need Rhogam following the procedure
MacrosomiaShoulder Dystociabull Wt gt 4500 gms (9-10 lbs)bull Associated with
bull DM Gestational DM Multiparity Postdates obesitybull Risks
bull Shoulder dystocia difficulty delivering the shoulders after head is delivered (obstetrical emergency)
bull Maternal vaginalcervical tears pp hemorrhage rupturebull Fetal compressed cord fractured clavical asphyxia amp neurologic
damage brachial plexus injury (ErbrsquosPalsy)bull SS Turtle signbull Nursing interventions McRoberts maneuvers suprapubic
pressure PP assess for uterine atonyhemorrhage trauma cerebral or neurologic damage to baby
Video youtubecomwatchv=jV6g427UMxYampfeature=related
McRoberts Maneuvers Video
Multiple Gestationbull Monozygotic (identical) twins can have 1 or 2 placentas
chorions or amnions (uarrrisk if all shared)bull Dizygotic (fraternal) twins 2 of everything
bull Dx faster than usual growth of uterus uarrAFP HCG Ultrasound
bull Risks bull Maternal SAB gestational DM HTNpreeclampsiaHELLP
hydramnios PT labor amp deliverybull Fetal Preterm birth twin-to-twin transfusion
Multiple Gestation (cont)bull Management
bull US to determine what type of twinsbull Prevention of PT laborroutine cervical measurements
(US)bull NST surveillance bull Birth depends on maternal amp fetal complications and
fetal position presentationbull Examination of placentabull Close monitoring PP for hemorrhage (atony)
Abruptio Placentaebull Premature separation of placenta from uterine wallbull SS sharp stabbing pain high in fundus heavy
bleeding (may be occult) hard board-like uterus tense painful uterus signs of shock due to blood loss Port-Wine aminotic fluid if ROM
bull Predisposing fx uarrparity adv maternal age short umbilical cord chronic HTN PIH direct trauma vasoconstriction from cocaine or cigarette use
bull Fetal distress on monitor Can progress to DIC
Abruptio Placentae (cont)bull Management
bull Emergency Immediate c-section if birth not imminent
bull Lg gauge IV bull O2 via mask fetal monitoring
maternal VS lateral positioning labs blood transfusion (have 2 units avail)
bull CBC (HampH) Fibrinogen levels platelet count PTPTT fibrin degradation products ( sx of DIC)
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
for pp hemorrhage
bull Table 26-6 pg 746 differential dx abruptioprevia
Low-lying Marginal
Partial Complete
Placenta Previas
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
Diabetes Pulmonary disease Pregnancy-induced hypertension)
bull Chorioamnionitisbull Suspected fetal problems- Intrauterine Growth
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Inductionbull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessmentbull Bishop Score- rating that determines if the cervix
is ready for induction--Pg 765bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole -Inadequate uterine relaxation between contractions lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveriesbull Forceps
bull Indications unable to push arrested descent need a quick delivery breech
bull Associated with maternalfetal birth trauma rectal sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
laborbull Elective
Placenta Factorsbull Placenta previabull Placental abruptionbull Umbilical cord prolapse
Fetal Factorsbull Breech transverse liebull Macrosomiabull Extreme low birth wtbull Fetal distressbull Fetal anomaliesbull Multiple gestation
Cesarean Birth (cont)bull Mortality
morbiditybull 4 x higher than
vaginal birth in US Most risk assoc with emergency c-section
bull Incisionbull Skin vs uterinebull Classical vs low
transverse
bull Maternal Complicationsbull Infectionbull Anesthesia reactionsbull DeepVeinThrombopheb
itisbull Bleedingbull Ureteralbladder injurybull Increase risk for
subsequent pregnancybull Placenta AcretaPrevia
Infertility
Cesarean Birthbull Pre-op CBC w platelets hold clotbull bicitraantacidbull monitor babybull Teaching pre amp post-op anesthesia recovery
breastfeedingbull Psychosocial issues
bull Fearbull Self-imageself-esteem
Post-Op Carebull Assess fundusbleeding vital signs DVTbull Antibiotics bull Pain Duramorph Breakthrough pain
meds Benadryl for itching Zofran for nausea
bull Clear liquids and advance as toleratedbull Assess for GI function Bowel sounds
Passing flatusbull Ambulation Pre-medicate teach splinting
with pillowbull Stool softener
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
multiparity excessive analgesia Afterpains wwwyoutubecomwatchv=EbItF_7KYCcampfeature=related
Fundal Assessment Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina Cervix returns to firm nongravid consistency
by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum Assessment turn pt to side in Simrsquos
position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments Constipation Give stool softeners as
ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis Superficial leg vein disease
ndash Ss tenderness in portion of vein local heat amp redness normal temperature or low-grade fever
ndash Tx local heat elevate limb bed rest analgesia elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation Engorgement day 3 or 4
ndash If breastfeeding Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
Postpartum Complications Postpartum Hemorrhage
ndash CAUSES Uterine atony lacerations retained placental fragments
Risk factorsndash uarr uterine distension multiples polyhydramnios
macrosomia fibroidsndash Trauma rapid or operative birthndash Placental problems previa accreta abruptio
retained placental fragmentsndash Atonic uterus prolonged pitocin magnesium
sulfate or labor uarr maternal age or parity uterine scar chorioamnionitis anemia prior history
ndash Inadequate blood coagulation fetal death or DIC
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
Stages of Labor Third Stage
bull Placental stage from birth to delivery of placenta
bull Placental separation from uterine wall (rise of fundus sudden gush of blood lengthening of umbilical cord)
bull Entire lining of uterus shedbull Expulsion of placenta
bull Normal blood loss 300-500 mLbull If placenta does not deliver spontaneously can
be delivered manuallybull Pitocin infusion started immediately post
delivery of placenta
Critical Thinkingbull
A client is admitted to the labor unit with contractions 2 to 3 minutes apart and lasting 60 to 90 seconds The client is apprehensive and vomiting This nurse understands this information to indicate that the client is most likely in what phase of labor
bull A) Active bull B) Transition bull C) Latent bull D) Second
Chapter 23Intrapartal Nursing Assessment
Initial Intrapartum AssessmentPages 608-612
bull Vital signsbull Fetal heart rate pattern fetal distressbull Contraction pattern intensity painbull Membrane status--intact ruptured nitrizine test
amniotic fluid clear meconium foul odorbull Prenatal records history of pregnancy
complications previous pregnancies and deliveries maternal health problems
bull Psychosocialfamilycultural issuesbull Labs CBC dip urine for protein glucose
ketonesbull Vaginal Exam--effacementdilationstation fetal
presentationlie Assesses LABOR PROGRESS
Intrauterine Fetal Resuscitation
bull Stop pitocinbull Reposition to left lateral Trendelenberg if neededbull Oxygen via mask at 8-10 Lminbull Increase IV fluidsbull SQ terbutaline (025 mg) if uterus not relaxingbull Vaginal exam for possible cause prolapse fetal
descent rupture abruptionbull Amnioinfusion for variable decelsbull Notify MDmidwife
Which strip shows signs thatImmediate intervention is needed Why What would you do
A
B
Experiences of Painbull Etiology bull Physiologybull Perception
bull Factors influencingAnxiety Psychological factorsExpectations Cultural factorsSupport Fetal position
Comfort and Pain Relief
bull Support from doula or coachbull Alternative therapies
bullRelaxationmassagebull Focusing and imagerybullBreathingbullHerbal preparationsaromatherapybullHypnosis
Comfort and Pain Reliefbull Pharmacological Measures
bullNarcotic analgesicsbullNubainStadolDemerol (pg 689)
bullRegional nerve blocksbullEpiduralspinal
bull Local anesthetic blocksbullPudendalperineal
Systemic AnalgesiaTable 25-3 pg 690
bull Pre-medication Assessment bull Pain level VS allergies drug dependence
(withdrawal) vaginal examprogress in labor UC pattern fetal heart rate tracing
bull Post-medication Assessmentbull VS esp RR LOC dizziness (bedpan)
sedation FHRbull Reversal agent Naloxone (Narcan)
bull Competes with narcotic for opiate receptors Used in both mom and baby (avoid with narcotic dependence)
Regional Anesthesiabull Injection of local anesthesia to block
specific nerve pathwaysbull Epiduralspinal anesthesia
bullSystemic toxicity cardiovascular collapsebullSide effects Hypotension (preload with IV
fluids) fetal distress on FHR tracing spinal HA
bullContradindications coagulation disorders low platelet count (lt 100) allergy neurologic disease aspirin use
bullNursing care Preload IV fluids (LR) monitor BP HR anesthesia level FHR foley cath maternal positioning
Epidural Anesthesia
Medication for Pain Relief Birthbull Local anesthesia
bull Pudendal nerve block (2nd stage episiotomy repair)bull Local infiltration in perineum (episiotomy repair)
bull General anesthesiabull Regional contraindicatedemergencybull Preparation hip wedge preoxygenation cricoid
pressure for intubationbull Complications fetal depression aspiration of
vomitus (Bicitra)
Local anesthesia for Episiotomy
Childbirth at Risk (Ch 26)
Complications of Labor or Delivery
Critical Thinking The client in active labor is requesting pain relief The
physician orders epidural anesthesia for the client Which of the following parameters should the nurse
be prepared to assess immediately after administration of the epidural
bull A) For headache bull B) For urinary retention bull C) The blood pressure bull D) The maternal pulse rate
Precipitous Labor amp Birthbull Labor in lt 3 hoursbull Risk factors
bull Multiparity oxytocin or amniotomy hx of precipitate labor
bull Risks for injurybull Maternal cervical vaginal amp perineal
lacerations with possible hemorrhage pain anxiety
bull Fetal Birth trauma (intracranial bleed brachial palsy) meconium-stained fluid fetal distress
bull Management close monitoring for cervical changes induction
Postterm Pregnancybull gt 42 weeksbull Maternal risks traumahemorrhage due
to larger baby uarroperative deliveryc-section
bull Fetal risks placental changes that darroxygenation to baby and uarrmortality rate oligohydramnios (uarrcord compression during labor) LGA baby (uarrbirth trauma shoulder dystocia) meconium aspiration
bull Management gt 40 wks NST BPP or modified BPP (NST amp AFI) induction
Malpresentationsbull Occiput-posterior (OP)
bull Prolonged labor back labor (sacral nerve compression) arrested dilatation descent perineal tears
bull Usually vaginal but may need C-Section if baby doesnrsquot rotate
bull Management positioning (side-lying knee-chest or hand-knees) sacral pressure during UCrsquos
bull Transverse Liebull Associated with pendulous abdomen uterine
massesfibroids congenital abnormalities of uterus hydramnios
bull Attempt External Cephalic Version if unsuccessful obligatory C-section
Malpresentations (cont)bull Breech presentation
Assessment FHT heard high on the abdomen Leopoldrsquos vaginal exam amp USbull Higher risk of anoxia from prolapsed cord traumatic injury to
the after coming head fracture of spine or arm dysfunctional labor
bull Usually delivered by C-section
External Versionbull External cephalic version (37-38 wks) abdominal
manipulation to change fetal presentationbull Contraindications multiple gestation fetal
breech is engaged in pelvis oligohydramnios nonreactive NST nuchal cord vaginal bleeding IUGR ROM
bull Risks immediate cesarean birthbull Nursing actions NPO 8 hrs NST IV line
terbutaline continuous FHR US used to guide manipulations assess for labor fetal distress O- moms need Rhogam following the procedure
MacrosomiaShoulder Dystociabull Wt gt 4500 gms (9-10 lbs)bull Associated with
bull DM Gestational DM Multiparity Postdates obesitybull Risks
bull Shoulder dystocia difficulty delivering the shoulders after head is delivered (obstetrical emergency)
bull Maternal vaginalcervical tears pp hemorrhage rupturebull Fetal compressed cord fractured clavical asphyxia amp neurologic
damage brachial plexus injury (ErbrsquosPalsy)bull SS Turtle signbull Nursing interventions McRoberts maneuvers suprapubic
pressure PP assess for uterine atonyhemorrhage trauma cerebral or neurologic damage to baby
Video youtubecomwatchv=jV6g427UMxYampfeature=related
McRoberts Maneuvers Video
Multiple Gestationbull Monozygotic (identical) twins can have 1 or 2 placentas
chorions or amnions (uarrrisk if all shared)bull Dizygotic (fraternal) twins 2 of everything
bull Dx faster than usual growth of uterus uarrAFP HCG Ultrasound
bull Risks bull Maternal SAB gestational DM HTNpreeclampsiaHELLP
hydramnios PT labor amp deliverybull Fetal Preterm birth twin-to-twin transfusion
Multiple Gestation (cont)bull Management
bull US to determine what type of twinsbull Prevention of PT laborroutine cervical measurements
(US)bull NST surveillance bull Birth depends on maternal amp fetal complications and
fetal position presentationbull Examination of placentabull Close monitoring PP for hemorrhage (atony)
Abruptio Placentaebull Premature separation of placenta from uterine wallbull SS sharp stabbing pain high in fundus heavy
bleeding (may be occult) hard board-like uterus tense painful uterus signs of shock due to blood loss Port-Wine aminotic fluid if ROM
bull Predisposing fx uarrparity adv maternal age short umbilical cord chronic HTN PIH direct trauma vasoconstriction from cocaine or cigarette use
bull Fetal distress on monitor Can progress to DIC
Abruptio Placentae (cont)bull Management
bull Emergency Immediate c-section if birth not imminent
bull Lg gauge IV bull O2 via mask fetal monitoring
maternal VS lateral positioning labs blood transfusion (have 2 units avail)
bull CBC (HampH) Fibrinogen levels platelet count PTPTT fibrin degradation products ( sx of DIC)
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
for pp hemorrhage
bull Table 26-6 pg 746 differential dx abruptioprevia
Low-lying Marginal
Partial Complete
Placenta Previas
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
Diabetes Pulmonary disease Pregnancy-induced hypertension)
bull Chorioamnionitisbull Suspected fetal problems- Intrauterine Growth
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Inductionbull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessmentbull Bishop Score- rating that determines if the cervix
is ready for induction--Pg 765bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole -Inadequate uterine relaxation between contractions lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveriesbull Forceps
bull Indications unable to push arrested descent need a quick delivery breech
bull Associated with maternalfetal birth trauma rectal sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
laborbull Elective
Placenta Factorsbull Placenta previabull Placental abruptionbull Umbilical cord prolapse
Fetal Factorsbull Breech transverse liebull Macrosomiabull Extreme low birth wtbull Fetal distressbull Fetal anomaliesbull Multiple gestation
Cesarean Birth (cont)bull Mortality
morbiditybull 4 x higher than
vaginal birth in US Most risk assoc with emergency c-section
bull Incisionbull Skin vs uterinebull Classical vs low
transverse
bull Maternal Complicationsbull Infectionbull Anesthesia reactionsbull DeepVeinThrombopheb
itisbull Bleedingbull Ureteralbladder injurybull Increase risk for
subsequent pregnancybull Placenta AcretaPrevia
Infertility
Cesarean Birthbull Pre-op CBC w platelets hold clotbull bicitraantacidbull monitor babybull Teaching pre amp post-op anesthesia recovery
breastfeedingbull Psychosocial issues
bull Fearbull Self-imageself-esteem
Post-Op Carebull Assess fundusbleeding vital signs DVTbull Antibiotics bull Pain Duramorph Breakthrough pain
meds Benadryl for itching Zofran for nausea
bull Clear liquids and advance as toleratedbull Assess for GI function Bowel sounds
Passing flatusbull Ambulation Pre-medicate teach splinting
with pillowbull Stool softener
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
multiparity excessive analgesia Afterpains wwwyoutubecomwatchv=EbItF_7KYCcampfeature=related
Fundal Assessment Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina Cervix returns to firm nongravid consistency
by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum Assessment turn pt to side in Simrsquos
position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments Constipation Give stool softeners as
ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis Superficial leg vein disease
ndash Ss tenderness in portion of vein local heat amp redness normal temperature or low-grade fever
ndash Tx local heat elevate limb bed rest analgesia elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation Engorgement day 3 or 4
ndash If breastfeeding Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
Postpartum Complications Postpartum Hemorrhage
ndash CAUSES Uterine atony lacerations retained placental fragments
Risk factorsndash uarr uterine distension multiples polyhydramnios
macrosomia fibroidsndash Trauma rapid or operative birthndash Placental problems previa accreta abruptio
retained placental fragmentsndash Atonic uterus prolonged pitocin magnesium
sulfate or labor uarr maternal age or parity uterine scar chorioamnionitis anemia prior history
ndash Inadequate blood coagulation fetal death or DIC
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
Critical Thinkingbull
A client is admitted to the labor unit with contractions 2 to 3 minutes apart and lasting 60 to 90 seconds The client is apprehensive and vomiting This nurse understands this information to indicate that the client is most likely in what phase of labor
bull A) Active bull B) Transition bull C) Latent bull D) Second
Chapter 23Intrapartal Nursing Assessment
Initial Intrapartum AssessmentPages 608-612
bull Vital signsbull Fetal heart rate pattern fetal distressbull Contraction pattern intensity painbull Membrane status--intact ruptured nitrizine test
amniotic fluid clear meconium foul odorbull Prenatal records history of pregnancy
complications previous pregnancies and deliveries maternal health problems
bull Psychosocialfamilycultural issuesbull Labs CBC dip urine for protein glucose
ketonesbull Vaginal Exam--effacementdilationstation fetal
presentationlie Assesses LABOR PROGRESS
Intrauterine Fetal Resuscitation
bull Stop pitocinbull Reposition to left lateral Trendelenberg if neededbull Oxygen via mask at 8-10 Lminbull Increase IV fluidsbull SQ terbutaline (025 mg) if uterus not relaxingbull Vaginal exam for possible cause prolapse fetal
descent rupture abruptionbull Amnioinfusion for variable decelsbull Notify MDmidwife
Which strip shows signs thatImmediate intervention is needed Why What would you do
A
B
Experiences of Painbull Etiology bull Physiologybull Perception
bull Factors influencingAnxiety Psychological factorsExpectations Cultural factorsSupport Fetal position
Comfort and Pain Relief
bull Support from doula or coachbull Alternative therapies
bullRelaxationmassagebull Focusing and imagerybullBreathingbullHerbal preparationsaromatherapybullHypnosis
Comfort and Pain Reliefbull Pharmacological Measures
bullNarcotic analgesicsbullNubainStadolDemerol (pg 689)
bullRegional nerve blocksbullEpiduralspinal
bull Local anesthetic blocksbullPudendalperineal
Systemic AnalgesiaTable 25-3 pg 690
bull Pre-medication Assessment bull Pain level VS allergies drug dependence
(withdrawal) vaginal examprogress in labor UC pattern fetal heart rate tracing
bull Post-medication Assessmentbull VS esp RR LOC dizziness (bedpan)
sedation FHRbull Reversal agent Naloxone (Narcan)
bull Competes with narcotic for opiate receptors Used in both mom and baby (avoid with narcotic dependence)
Regional Anesthesiabull Injection of local anesthesia to block
specific nerve pathwaysbull Epiduralspinal anesthesia
bullSystemic toxicity cardiovascular collapsebullSide effects Hypotension (preload with IV
fluids) fetal distress on FHR tracing spinal HA
bullContradindications coagulation disorders low platelet count (lt 100) allergy neurologic disease aspirin use
bullNursing care Preload IV fluids (LR) monitor BP HR anesthesia level FHR foley cath maternal positioning
Epidural Anesthesia
Medication for Pain Relief Birthbull Local anesthesia
bull Pudendal nerve block (2nd stage episiotomy repair)bull Local infiltration in perineum (episiotomy repair)
bull General anesthesiabull Regional contraindicatedemergencybull Preparation hip wedge preoxygenation cricoid
pressure for intubationbull Complications fetal depression aspiration of
vomitus (Bicitra)
Local anesthesia for Episiotomy
Childbirth at Risk (Ch 26)
Complications of Labor or Delivery
Critical Thinking The client in active labor is requesting pain relief The
physician orders epidural anesthesia for the client Which of the following parameters should the nurse
be prepared to assess immediately after administration of the epidural
bull A) For headache bull B) For urinary retention bull C) The blood pressure bull D) The maternal pulse rate
Precipitous Labor amp Birthbull Labor in lt 3 hoursbull Risk factors
bull Multiparity oxytocin or amniotomy hx of precipitate labor
bull Risks for injurybull Maternal cervical vaginal amp perineal
lacerations with possible hemorrhage pain anxiety
bull Fetal Birth trauma (intracranial bleed brachial palsy) meconium-stained fluid fetal distress
bull Management close monitoring for cervical changes induction
Postterm Pregnancybull gt 42 weeksbull Maternal risks traumahemorrhage due
to larger baby uarroperative deliveryc-section
bull Fetal risks placental changes that darroxygenation to baby and uarrmortality rate oligohydramnios (uarrcord compression during labor) LGA baby (uarrbirth trauma shoulder dystocia) meconium aspiration
bull Management gt 40 wks NST BPP or modified BPP (NST amp AFI) induction
Malpresentationsbull Occiput-posterior (OP)
bull Prolonged labor back labor (sacral nerve compression) arrested dilatation descent perineal tears
bull Usually vaginal but may need C-Section if baby doesnrsquot rotate
bull Management positioning (side-lying knee-chest or hand-knees) sacral pressure during UCrsquos
bull Transverse Liebull Associated with pendulous abdomen uterine
massesfibroids congenital abnormalities of uterus hydramnios
bull Attempt External Cephalic Version if unsuccessful obligatory C-section
Malpresentations (cont)bull Breech presentation
Assessment FHT heard high on the abdomen Leopoldrsquos vaginal exam amp USbull Higher risk of anoxia from prolapsed cord traumatic injury to
the after coming head fracture of spine or arm dysfunctional labor
bull Usually delivered by C-section
External Versionbull External cephalic version (37-38 wks) abdominal
manipulation to change fetal presentationbull Contraindications multiple gestation fetal
breech is engaged in pelvis oligohydramnios nonreactive NST nuchal cord vaginal bleeding IUGR ROM
bull Risks immediate cesarean birthbull Nursing actions NPO 8 hrs NST IV line
terbutaline continuous FHR US used to guide manipulations assess for labor fetal distress O- moms need Rhogam following the procedure
MacrosomiaShoulder Dystociabull Wt gt 4500 gms (9-10 lbs)bull Associated with
bull DM Gestational DM Multiparity Postdates obesitybull Risks
bull Shoulder dystocia difficulty delivering the shoulders after head is delivered (obstetrical emergency)
bull Maternal vaginalcervical tears pp hemorrhage rupturebull Fetal compressed cord fractured clavical asphyxia amp neurologic
damage brachial plexus injury (ErbrsquosPalsy)bull SS Turtle signbull Nursing interventions McRoberts maneuvers suprapubic
pressure PP assess for uterine atonyhemorrhage trauma cerebral or neurologic damage to baby
Video youtubecomwatchv=jV6g427UMxYampfeature=related
McRoberts Maneuvers Video
Multiple Gestationbull Monozygotic (identical) twins can have 1 or 2 placentas
chorions or amnions (uarrrisk if all shared)bull Dizygotic (fraternal) twins 2 of everything
bull Dx faster than usual growth of uterus uarrAFP HCG Ultrasound
bull Risks bull Maternal SAB gestational DM HTNpreeclampsiaHELLP
hydramnios PT labor amp deliverybull Fetal Preterm birth twin-to-twin transfusion
Multiple Gestation (cont)bull Management
bull US to determine what type of twinsbull Prevention of PT laborroutine cervical measurements
(US)bull NST surveillance bull Birth depends on maternal amp fetal complications and
fetal position presentationbull Examination of placentabull Close monitoring PP for hemorrhage (atony)
Abruptio Placentaebull Premature separation of placenta from uterine wallbull SS sharp stabbing pain high in fundus heavy
bleeding (may be occult) hard board-like uterus tense painful uterus signs of shock due to blood loss Port-Wine aminotic fluid if ROM
bull Predisposing fx uarrparity adv maternal age short umbilical cord chronic HTN PIH direct trauma vasoconstriction from cocaine or cigarette use
bull Fetal distress on monitor Can progress to DIC
Abruptio Placentae (cont)bull Management
bull Emergency Immediate c-section if birth not imminent
bull Lg gauge IV bull O2 via mask fetal monitoring
maternal VS lateral positioning labs blood transfusion (have 2 units avail)
bull CBC (HampH) Fibrinogen levels platelet count PTPTT fibrin degradation products ( sx of DIC)
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
for pp hemorrhage
bull Table 26-6 pg 746 differential dx abruptioprevia
Low-lying Marginal
Partial Complete
Placenta Previas
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
Diabetes Pulmonary disease Pregnancy-induced hypertension)
bull Chorioamnionitisbull Suspected fetal problems- Intrauterine Growth
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Inductionbull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessmentbull Bishop Score- rating that determines if the cervix
is ready for induction--Pg 765bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole -Inadequate uterine relaxation between contractions lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveriesbull Forceps
bull Indications unable to push arrested descent need a quick delivery breech
bull Associated with maternalfetal birth trauma rectal sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
laborbull Elective
Placenta Factorsbull Placenta previabull Placental abruptionbull Umbilical cord prolapse
Fetal Factorsbull Breech transverse liebull Macrosomiabull Extreme low birth wtbull Fetal distressbull Fetal anomaliesbull Multiple gestation
Cesarean Birth (cont)bull Mortality
morbiditybull 4 x higher than
vaginal birth in US Most risk assoc with emergency c-section
bull Incisionbull Skin vs uterinebull Classical vs low
transverse
bull Maternal Complicationsbull Infectionbull Anesthesia reactionsbull DeepVeinThrombopheb
itisbull Bleedingbull Ureteralbladder injurybull Increase risk for
subsequent pregnancybull Placenta AcretaPrevia
Infertility
Cesarean Birthbull Pre-op CBC w platelets hold clotbull bicitraantacidbull monitor babybull Teaching pre amp post-op anesthesia recovery
breastfeedingbull Psychosocial issues
bull Fearbull Self-imageself-esteem
Post-Op Carebull Assess fundusbleeding vital signs DVTbull Antibiotics bull Pain Duramorph Breakthrough pain
meds Benadryl for itching Zofran for nausea
bull Clear liquids and advance as toleratedbull Assess for GI function Bowel sounds
Passing flatusbull Ambulation Pre-medicate teach splinting
with pillowbull Stool softener
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
multiparity excessive analgesia Afterpains wwwyoutubecomwatchv=EbItF_7KYCcampfeature=related
Fundal Assessment Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina Cervix returns to firm nongravid consistency
by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum Assessment turn pt to side in Simrsquos
position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments Constipation Give stool softeners as
ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis Superficial leg vein disease
ndash Ss tenderness in portion of vein local heat amp redness normal temperature or low-grade fever
ndash Tx local heat elevate limb bed rest analgesia elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation Engorgement day 3 or 4
ndash If breastfeeding Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
Postpartum Complications Postpartum Hemorrhage
ndash CAUSES Uterine atony lacerations retained placental fragments
Risk factorsndash uarr uterine distension multiples polyhydramnios
macrosomia fibroidsndash Trauma rapid or operative birthndash Placental problems previa accreta abruptio
retained placental fragmentsndash Atonic uterus prolonged pitocin magnesium
sulfate or labor uarr maternal age or parity uterine scar chorioamnionitis anemia prior history
ndash Inadequate blood coagulation fetal death or DIC
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
Chapter 23Intrapartal Nursing Assessment
Initial Intrapartum AssessmentPages 608-612
bull Vital signsbull Fetal heart rate pattern fetal distressbull Contraction pattern intensity painbull Membrane status--intact ruptured nitrizine test
amniotic fluid clear meconium foul odorbull Prenatal records history of pregnancy
complications previous pregnancies and deliveries maternal health problems
bull Psychosocialfamilycultural issuesbull Labs CBC dip urine for protein glucose
ketonesbull Vaginal Exam--effacementdilationstation fetal
presentationlie Assesses LABOR PROGRESS
Intrauterine Fetal Resuscitation
bull Stop pitocinbull Reposition to left lateral Trendelenberg if neededbull Oxygen via mask at 8-10 Lminbull Increase IV fluidsbull SQ terbutaline (025 mg) if uterus not relaxingbull Vaginal exam for possible cause prolapse fetal
descent rupture abruptionbull Amnioinfusion for variable decelsbull Notify MDmidwife
Which strip shows signs thatImmediate intervention is needed Why What would you do
A
B
Experiences of Painbull Etiology bull Physiologybull Perception
bull Factors influencingAnxiety Psychological factorsExpectations Cultural factorsSupport Fetal position
Comfort and Pain Relief
bull Support from doula or coachbull Alternative therapies
bullRelaxationmassagebull Focusing and imagerybullBreathingbullHerbal preparationsaromatherapybullHypnosis
Comfort and Pain Reliefbull Pharmacological Measures
bullNarcotic analgesicsbullNubainStadolDemerol (pg 689)
bullRegional nerve blocksbullEpiduralspinal
bull Local anesthetic blocksbullPudendalperineal
Systemic AnalgesiaTable 25-3 pg 690
bull Pre-medication Assessment bull Pain level VS allergies drug dependence
(withdrawal) vaginal examprogress in labor UC pattern fetal heart rate tracing
bull Post-medication Assessmentbull VS esp RR LOC dizziness (bedpan)
sedation FHRbull Reversal agent Naloxone (Narcan)
bull Competes with narcotic for opiate receptors Used in both mom and baby (avoid with narcotic dependence)
Regional Anesthesiabull Injection of local anesthesia to block
specific nerve pathwaysbull Epiduralspinal anesthesia
bullSystemic toxicity cardiovascular collapsebullSide effects Hypotension (preload with IV
fluids) fetal distress on FHR tracing spinal HA
bullContradindications coagulation disorders low platelet count (lt 100) allergy neurologic disease aspirin use
bullNursing care Preload IV fluids (LR) monitor BP HR anesthesia level FHR foley cath maternal positioning
Epidural Anesthesia
Medication for Pain Relief Birthbull Local anesthesia
bull Pudendal nerve block (2nd stage episiotomy repair)bull Local infiltration in perineum (episiotomy repair)
bull General anesthesiabull Regional contraindicatedemergencybull Preparation hip wedge preoxygenation cricoid
pressure for intubationbull Complications fetal depression aspiration of
vomitus (Bicitra)
Local anesthesia for Episiotomy
Childbirth at Risk (Ch 26)
Complications of Labor or Delivery
Critical Thinking The client in active labor is requesting pain relief The
physician orders epidural anesthesia for the client Which of the following parameters should the nurse
be prepared to assess immediately after administration of the epidural
bull A) For headache bull B) For urinary retention bull C) The blood pressure bull D) The maternal pulse rate
Precipitous Labor amp Birthbull Labor in lt 3 hoursbull Risk factors
bull Multiparity oxytocin or amniotomy hx of precipitate labor
bull Risks for injurybull Maternal cervical vaginal amp perineal
lacerations with possible hemorrhage pain anxiety
bull Fetal Birth trauma (intracranial bleed brachial palsy) meconium-stained fluid fetal distress
bull Management close monitoring for cervical changes induction
Postterm Pregnancybull gt 42 weeksbull Maternal risks traumahemorrhage due
to larger baby uarroperative deliveryc-section
bull Fetal risks placental changes that darroxygenation to baby and uarrmortality rate oligohydramnios (uarrcord compression during labor) LGA baby (uarrbirth trauma shoulder dystocia) meconium aspiration
bull Management gt 40 wks NST BPP or modified BPP (NST amp AFI) induction
Malpresentationsbull Occiput-posterior (OP)
bull Prolonged labor back labor (sacral nerve compression) arrested dilatation descent perineal tears
bull Usually vaginal but may need C-Section if baby doesnrsquot rotate
bull Management positioning (side-lying knee-chest or hand-knees) sacral pressure during UCrsquos
bull Transverse Liebull Associated with pendulous abdomen uterine
massesfibroids congenital abnormalities of uterus hydramnios
bull Attempt External Cephalic Version if unsuccessful obligatory C-section
Malpresentations (cont)bull Breech presentation
Assessment FHT heard high on the abdomen Leopoldrsquos vaginal exam amp USbull Higher risk of anoxia from prolapsed cord traumatic injury to
the after coming head fracture of spine or arm dysfunctional labor
bull Usually delivered by C-section
External Versionbull External cephalic version (37-38 wks) abdominal
manipulation to change fetal presentationbull Contraindications multiple gestation fetal
breech is engaged in pelvis oligohydramnios nonreactive NST nuchal cord vaginal bleeding IUGR ROM
bull Risks immediate cesarean birthbull Nursing actions NPO 8 hrs NST IV line
terbutaline continuous FHR US used to guide manipulations assess for labor fetal distress O- moms need Rhogam following the procedure
MacrosomiaShoulder Dystociabull Wt gt 4500 gms (9-10 lbs)bull Associated with
bull DM Gestational DM Multiparity Postdates obesitybull Risks
bull Shoulder dystocia difficulty delivering the shoulders after head is delivered (obstetrical emergency)
bull Maternal vaginalcervical tears pp hemorrhage rupturebull Fetal compressed cord fractured clavical asphyxia amp neurologic
damage brachial plexus injury (ErbrsquosPalsy)bull SS Turtle signbull Nursing interventions McRoberts maneuvers suprapubic
pressure PP assess for uterine atonyhemorrhage trauma cerebral or neurologic damage to baby
Video youtubecomwatchv=jV6g427UMxYampfeature=related
McRoberts Maneuvers Video
Multiple Gestationbull Monozygotic (identical) twins can have 1 or 2 placentas
chorions or amnions (uarrrisk if all shared)bull Dizygotic (fraternal) twins 2 of everything
bull Dx faster than usual growth of uterus uarrAFP HCG Ultrasound
bull Risks bull Maternal SAB gestational DM HTNpreeclampsiaHELLP
hydramnios PT labor amp deliverybull Fetal Preterm birth twin-to-twin transfusion
Multiple Gestation (cont)bull Management
bull US to determine what type of twinsbull Prevention of PT laborroutine cervical measurements
(US)bull NST surveillance bull Birth depends on maternal amp fetal complications and
fetal position presentationbull Examination of placentabull Close monitoring PP for hemorrhage (atony)
Abruptio Placentaebull Premature separation of placenta from uterine wallbull SS sharp stabbing pain high in fundus heavy
bleeding (may be occult) hard board-like uterus tense painful uterus signs of shock due to blood loss Port-Wine aminotic fluid if ROM
bull Predisposing fx uarrparity adv maternal age short umbilical cord chronic HTN PIH direct trauma vasoconstriction from cocaine or cigarette use
bull Fetal distress on monitor Can progress to DIC
Abruptio Placentae (cont)bull Management
bull Emergency Immediate c-section if birth not imminent
bull Lg gauge IV bull O2 via mask fetal monitoring
maternal VS lateral positioning labs blood transfusion (have 2 units avail)
bull CBC (HampH) Fibrinogen levels platelet count PTPTT fibrin degradation products ( sx of DIC)
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
for pp hemorrhage
bull Table 26-6 pg 746 differential dx abruptioprevia
Low-lying Marginal
Partial Complete
Placenta Previas
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
Diabetes Pulmonary disease Pregnancy-induced hypertension)
bull Chorioamnionitisbull Suspected fetal problems- Intrauterine Growth
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Inductionbull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessmentbull Bishop Score- rating that determines if the cervix
is ready for induction--Pg 765bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole -Inadequate uterine relaxation between contractions lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveriesbull Forceps
bull Indications unable to push arrested descent need a quick delivery breech
bull Associated with maternalfetal birth trauma rectal sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
laborbull Elective
Placenta Factorsbull Placenta previabull Placental abruptionbull Umbilical cord prolapse
Fetal Factorsbull Breech transverse liebull Macrosomiabull Extreme low birth wtbull Fetal distressbull Fetal anomaliesbull Multiple gestation
Cesarean Birth (cont)bull Mortality
morbiditybull 4 x higher than
vaginal birth in US Most risk assoc with emergency c-section
bull Incisionbull Skin vs uterinebull Classical vs low
transverse
bull Maternal Complicationsbull Infectionbull Anesthesia reactionsbull DeepVeinThrombopheb
itisbull Bleedingbull Ureteralbladder injurybull Increase risk for
subsequent pregnancybull Placenta AcretaPrevia
Infertility
Cesarean Birthbull Pre-op CBC w platelets hold clotbull bicitraantacidbull monitor babybull Teaching pre amp post-op anesthesia recovery
breastfeedingbull Psychosocial issues
bull Fearbull Self-imageself-esteem
Post-Op Carebull Assess fundusbleeding vital signs DVTbull Antibiotics bull Pain Duramorph Breakthrough pain
meds Benadryl for itching Zofran for nausea
bull Clear liquids and advance as toleratedbull Assess for GI function Bowel sounds
Passing flatusbull Ambulation Pre-medicate teach splinting
with pillowbull Stool softener
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
multiparity excessive analgesia Afterpains wwwyoutubecomwatchv=EbItF_7KYCcampfeature=related
Fundal Assessment Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina Cervix returns to firm nongravid consistency
by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum Assessment turn pt to side in Simrsquos
position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments Constipation Give stool softeners as
ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis Superficial leg vein disease
ndash Ss tenderness in portion of vein local heat amp redness normal temperature or low-grade fever
ndash Tx local heat elevate limb bed rest analgesia elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation Engorgement day 3 or 4
ndash If breastfeeding Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
Postpartum Complications Postpartum Hemorrhage
ndash CAUSES Uterine atony lacerations retained placental fragments
Risk factorsndash uarr uterine distension multiples polyhydramnios
macrosomia fibroidsndash Trauma rapid or operative birthndash Placental problems previa accreta abruptio
retained placental fragmentsndash Atonic uterus prolonged pitocin magnesium
sulfate or labor uarr maternal age or parity uterine scar chorioamnionitis anemia prior history
ndash Inadequate blood coagulation fetal death or DIC
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
Initial Intrapartum AssessmentPages 608-612
bull Vital signsbull Fetal heart rate pattern fetal distressbull Contraction pattern intensity painbull Membrane status--intact ruptured nitrizine test
amniotic fluid clear meconium foul odorbull Prenatal records history of pregnancy
complications previous pregnancies and deliveries maternal health problems
bull Psychosocialfamilycultural issuesbull Labs CBC dip urine for protein glucose
ketonesbull Vaginal Exam--effacementdilationstation fetal
presentationlie Assesses LABOR PROGRESS
Intrauterine Fetal Resuscitation
bull Stop pitocinbull Reposition to left lateral Trendelenberg if neededbull Oxygen via mask at 8-10 Lminbull Increase IV fluidsbull SQ terbutaline (025 mg) if uterus not relaxingbull Vaginal exam for possible cause prolapse fetal
descent rupture abruptionbull Amnioinfusion for variable decelsbull Notify MDmidwife
Which strip shows signs thatImmediate intervention is needed Why What would you do
A
B
Experiences of Painbull Etiology bull Physiologybull Perception
bull Factors influencingAnxiety Psychological factorsExpectations Cultural factorsSupport Fetal position
Comfort and Pain Relief
bull Support from doula or coachbull Alternative therapies
bullRelaxationmassagebull Focusing and imagerybullBreathingbullHerbal preparationsaromatherapybullHypnosis
Comfort and Pain Reliefbull Pharmacological Measures
bullNarcotic analgesicsbullNubainStadolDemerol (pg 689)
bullRegional nerve blocksbullEpiduralspinal
bull Local anesthetic blocksbullPudendalperineal
Systemic AnalgesiaTable 25-3 pg 690
bull Pre-medication Assessment bull Pain level VS allergies drug dependence
(withdrawal) vaginal examprogress in labor UC pattern fetal heart rate tracing
bull Post-medication Assessmentbull VS esp RR LOC dizziness (bedpan)
sedation FHRbull Reversal agent Naloxone (Narcan)
bull Competes with narcotic for opiate receptors Used in both mom and baby (avoid with narcotic dependence)
Regional Anesthesiabull Injection of local anesthesia to block
specific nerve pathwaysbull Epiduralspinal anesthesia
bullSystemic toxicity cardiovascular collapsebullSide effects Hypotension (preload with IV
fluids) fetal distress on FHR tracing spinal HA
bullContradindications coagulation disorders low platelet count (lt 100) allergy neurologic disease aspirin use
bullNursing care Preload IV fluids (LR) monitor BP HR anesthesia level FHR foley cath maternal positioning
Epidural Anesthesia
Medication for Pain Relief Birthbull Local anesthesia
bull Pudendal nerve block (2nd stage episiotomy repair)bull Local infiltration in perineum (episiotomy repair)
bull General anesthesiabull Regional contraindicatedemergencybull Preparation hip wedge preoxygenation cricoid
pressure for intubationbull Complications fetal depression aspiration of
vomitus (Bicitra)
Local anesthesia for Episiotomy
Childbirth at Risk (Ch 26)
Complications of Labor or Delivery
Critical Thinking The client in active labor is requesting pain relief The
physician orders epidural anesthesia for the client Which of the following parameters should the nurse
be prepared to assess immediately after administration of the epidural
bull A) For headache bull B) For urinary retention bull C) The blood pressure bull D) The maternal pulse rate
Precipitous Labor amp Birthbull Labor in lt 3 hoursbull Risk factors
bull Multiparity oxytocin or amniotomy hx of precipitate labor
bull Risks for injurybull Maternal cervical vaginal amp perineal
lacerations with possible hemorrhage pain anxiety
bull Fetal Birth trauma (intracranial bleed brachial palsy) meconium-stained fluid fetal distress
bull Management close monitoring for cervical changes induction
Postterm Pregnancybull gt 42 weeksbull Maternal risks traumahemorrhage due
to larger baby uarroperative deliveryc-section
bull Fetal risks placental changes that darroxygenation to baby and uarrmortality rate oligohydramnios (uarrcord compression during labor) LGA baby (uarrbirth trauma shoulder dystocia) meconium aspiration
bull Management gt 40 wks NST BPP or modified BPP (NST amp AFI) induction
Malpresentationsbull Occiput-posterior (OP)
bull Prolonged labor back labor (sacral nerve compression) arrested dilatation descent perineal tears
bull Usually vaginal but may need C-Section if baby doesnrsquot rotate
bull Management positioning (side-lying knee-chest or hand-knees) sacral pressure during UCrsquos
bull Transverse Liebull Associated with pendulous abdomen uterine
massesfibroids congenital abnormalities of uterus hydramnios
bull Attempt External Cephalic Version if unsuccessful obligatory C-section
Malpresentations (cont)bull Breech presentation
Assessment FHT heard high on the abdomen Leopoldrsquos vaginal exam amp USbull Higher risk of anoxia from prolapsed cord traumatic injury to
the after coming head fracture of spine or arm dysfunctional labor
bull Usually delivered by C-section
External Versionbull External cephalic version (37-38 wks) abdominal
manipulation to change fetal presentationbull Contraindications multiple gestation fetal
breech is engaged in pelvis oligohydramnios nonreactive NST nuchal cord vaginal bleeding IUGR ROM
bull Risks immediate cesarean birthbull Nursing actions NPO 8 hrs NST IV line
terbutaline continuous FHR US used to guide manipulations assess for labor fetal distress O- moms need Rhogam following the procedure
MacrosomiaShoulder Dystociabull Wt gt 4500 gms (9-10 lbs)bull Associated with
bull DM Gestational DM Multiparity Postdates obesitybull Risks
bull Shoulder dystocia difficulty delivering the shoulders after head is delivered (obstetrical emergency)
bull Maternal vaginalcervical tears pp hemorrhage rupturebull Fetal compressed cord fractured clavical asphyxia amp neurologic
damage brachial plexus injury (ErbrsquosPalsy)bull SS Turtle signbull Nursing interventions McRoberts maneuvers suprapubic
pressure PP assess for uterine atonyhemorrhage trauma cerebral or neurologic damage to baby
Video youtubecomwatchv=jV6g427UMxYampfeature=related
McRoberts Maneuvers Video
Multiple Gestationbull Monozygotic (identical) twins can have 1 or 2 placentas
chorions or amnions (uarrrisk if all shared)bull Dizygotic (fraternal) twins 2 of everything
bull Dx faster than usual growth of uterus uarrAFP HCG Ultrasound
bull Risks bull Maternal SAB gestational DM HTNpreeclampsiaHELLP
hydramnios PT labor amp deliverybull Fetal Preterm birth twin-to-twin transfusion
Multiple Gestation (cont)bull Management
bull US to determine what type of twinsbull Prevention of PT laborroutine cervical measurements
(US)bull NST surveillance bull Birth depends on maternal amp fetal complications and
fetal position presentationbull Examination of placentabull Close monitoring PP for hemorrhage (atony)
Abruptio Placentaebull Premature separation of placenta from uterine wallbull SS sharp stabbing pain high in fundus heavy
bleeding (may be occult) hard board-like uterus tense painful uterus signs of shock due to blood loss Port-Wine aminotic fluid if ROM
bull Predisposing fx uarrparity adv maternal age short umbilical cord chronic HTN PIH direct trauma vasoconstriction from cocaine or cigarette use
bull Fetal distress on monitor Can progress to DIC
Abruptio Placentae (cont)bull Management
bull Emergency Immediate c-section if birth not imminent
bull Lg gauge IV bull O2 via mask fetal monitoring
maternal VS lateral positioning labs blood transfusion (have 2 units avail)
bull CBC (HampH) Fibrinogen levels platelet count PTPTT fibrin degradation products ( sx of DIC)
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
for pp hemorrhage
bull Table 26-6 pg 746 differential dx abruptioprevia
Low-lying Marginal
Partial Complete
Placenta Previas
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
Diabetes Pulmonary disease Pregnancy-induced hypertension)
bull Chorioamnionitisbull Suspected fetal problems- Intrauterine Growth
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Inductionbull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessmentbull Bishop Score- rating that determines if the cervix
is ready for induction--Pg 765bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole -Inadequate uterine relaxation between contractions lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveriesbull Forceps
bull Indications unable to push arrested descent need a quick delivery breech
bull Associated with maternalfetal birth trauma rectal sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
laborbull Elective
Placenta Factorsbull Placenta previabull Placental abruptionbull Umbilical cord prolapse
Fetal Factorsbull Breech transverse liebull Macrosomiabull Extreme low birth wtbull Fetal distressbull Fetal anomaliesbull Multiple gestation
Cesarean Birth (cont)bull Mortality
morbiditybull 4 x higher than
vaginal birth in US Most risk assoc with emergency c-section
bull Incisionbull Skin vs uterinebull Classical vs low
transverse
bull Maternal Complicationsbull Infectionbull Anesthesia reactionsbull DeepVeinThrombopheb
itisbull Bleedingbull Ureteralbladder injurybull Increase risk for
subsequent pregnancybull Placenta AcretaPrevia
Infertility
Cesarean Birthbull Pre-op CBC w platelets hold clotbull bicitraantacidbull monitor babybull Teaching pre amp post-op anesthesia recovery
breastfeedingbull Psychosocial issues
bull Fearbull Self-imageself-esteem
Post-Op Carebull Assess fundusbleeding vital signs DVTbull Antibiotics bull Pain Duramorph Breakthrough pain
meds Benadryl for itching Zofran for nausea
bull Clear liquids and advance as toleratedbull Assess for GI function Bowel sounds
Passing flatusbull Ambulation Pre-medicate teach splinting
with pillowbull Stool softener
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
multiparity excessive analgesia Afterpains wwwyoutubecomwatchv=EbItF_7KYCcampfeature=related
Fundal Assessment Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina Cervix returns to firm nongravid consistency
by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum Assessment turn pt to side in Simrsquos
position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments Constipation Give stool softeners as
ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis Superficial leg vein disease
ndash Ss tenderness in portion of vein local heat amp redness normal temperature or low-grade fever
ndash Tx local heat elevate limb bed rest analgesia elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation Engorgement day 3 or 4
ndash If breastfeeding Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
Postpartum Complications Postpartum Hemorrhage
ndash CAUSES Uterine atony lacerations retained placental fragments
Risk factorsndash uarr uterine distension multiples polyhydramnios
macrosomia fibroidsndash Trauma rapid or operative birthndash Placental problems previa accreta abruptio
retained placental fragmentsndash Atonic uterus prolonged pitocin magnesium
sulfate or labor uarr maternal age or parity uterine scar chorioamnionitis anemia prior history
ndash Inadequate blood coagulation fetal death or DIC
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
Intrauterine Fetal Resuscitation
bull Stop pitocinbull Reposition to left lateral Trendelenberg if neededbull Oxygen via mask at 8-10 Lminbull Increase IV fluidsbull SQ terbutaline (025 mg) if uterus not relaxingbull Vaginal exam for possible cause prolapse fetal
descent rupture abruptionbull Amnioinfusion for variable decelsbull Notify MDmidwife
Which strip shows signs thatImmediate intervention is needed Why What would you do
A
B
Experiences of Painbull Etiology bull Physiologybull Perception
bull Factors influencingAnxiety Psychological factorsExpectations Cultural factorsSupport Fetal position
Comfort and Pain Relief
bull Support from doula or coachbull Alternative therapies
bullRelaxationmassagebull Focusing and imagerybullBreathingbullHerbal preparationsaromatherapybullHypnosis
Comfort and Pain Reliefbull Pharmacological Measures
bullNarcotic analgesicsbullNubainStadolDemerol (pg 689)
bullRegional nerve blocksbullEpiduralspinal
bull Local anesthetic blocksbullPudendalperineal
Systemic AnalgesiaTable 25-3 pg 690
bull Pre-medication Assessment bull Pain level VS allergies drug dependence
(withdrawal) vaginal examprogress in labor UC pattern fetal heart rate tracing
bull Post-medication Assessmentbull VS esp RR LOC dizziness (bedpan)
sedation FHRbull Reversal agent Naloxone (Narcan)
bull Competes with narcotic for opiate receptors Used in both mom and baby (avoid with narcotic dependence)
Regional Anesthesiabull Injection of local anesthesia to block
specific nerve pathwaysbull Epiduralspinal anesthesia
bullSystemic toxicity cardiovascular collapsebullSide effects Hypotension (preload with IV
fluids) fetal distress on FHR tracing spinal HA
bullContradindications coagulation disorders low platelet count (lt 100) allergy neurologic disease aspirin use
bullNursing care Preload IV fluids (LR) monitor BP HR anesthesia level FHR foley cath maternal positioning
Epidural Anesthesia
Medication for Pain Relief Birthbull Local anesthesia
bull Pudendal nerve block (2nd stage episiotomy repair)bull Local infiltration in perineum (episiotomy repair)
bull General anesthesiabull Regional contraindicatedemergencybull Preparation hip wedge preoxygenation cricoid
pressure for intubationbull Complications fetal depression aspiration of
vomitus (Bicitra)
Local anesthesia for Episiotomy
Childbirth at Risk (Ch 26)
Complications of Labor or Delivery
Critical Thinking The client in active labor is requesting pain relief The
physician orders epidural anesthesia for the client Which of the following parameters should the nurse
be prepared to assess immediately after administration of the epidural
bull A) For headache bull B) For urinary retention bull C) The blood pressure bull D) The maternal pulse rate
Precipitous Labor amp Birthbull Labor in lt 3 hoursbull Risk factors
bull Multiparity oxytocin or amniotomy hx of precipitate labor
bull Risks for injurybull Maternal cervical vaginal amp perineal
lacerations with possible hemorrhage pain anxiety
bull Fetal Birth trauma (intracranial bleed brachial palsy) meconium-stained fluid fetal distress
bull Management close monitoring for cervical changes induction
Postterm Pregnancybull gt 42 weeksbull Maternal risks traumahemorrhage due
to larger baby uarroperative deliveryc-section
bull Fetal risks placental changes that darroxygenation to baby and uarrmortality rate oligohydramnios (uarrcord compression during labor) LGA baby (uarrbirth trauma shoulder dystocia) meconium aspiration
bull Management gt 40 wks NST BPP or modified BPP (NST amp AFI) induction
Malpresentationsbull Occiput-posterior (OP)
bull Prolonged labor back labor (sacral nerve compression) arrested dilatation descent perineal tears
bull Usually vaginal but may need C-Section if baby doesnrsquot rotate
bull Management positioning (side-lying knee-chest or hand-knees) sacral pressure during UCrsquos
bull Transverse Liebull Associated with pendulous abdomen uterine
massesfibroids congenital abnormalities of uterus hydramnios
bull Attempt External Cephalic Version if unsuccessful obligatory C-section
Malpresentations (cont)bull Breech presentation
Assessment FHT heard high on the abdomen Leopoldrsquos vaginal exam amp USbull Higher risk of anoxia from prolapsed cord traumatic injury to
the after coming head fracture of spine or arm dysfunctional labor
bull Usually delivered by C-section
External Versionbull External cephalic version (37-38 wks) abdominal
manipulation to change fetal presentationbull Contraindications multiple gestation fetal
breech is engaged in pelvis oligohydramnios nonreactive NST nuchal cord vaginal bleeding IUGR ROM
bull Risks immediate cesarean birthbull Nursing actions NPO 8 hrs NST IV line
terbutaline continuous FHR US used to guide manipulations assess for labor fetal distress O- moms need Rhogam following the procedure
MacrosomiaShoulder Dystociabull Wt gt 4500 gms (9-10 lbs)bull Associated with
bull DM Gestational DM Multiparity Postdates obesitybull Risks
bull Shoulder dystocia difficulty delivering the shoulders after head is delivered (obstetrical emergency)
bull Maternal vaginalcervical tears pp hemorrhage rupturebull Fetal compressed cord fractured clavical asphyxia amp neurologic
damage brachial plexus injury (ErbrsquosPalsy)bull SS Turtle signbull Nursing interventions McRoberts maneuvers suprapubic
pressure PP assess for uterine atonyhemorrhage trauma cerebral or neurologic damage to baby
Video youtubecomwatchv=jV6g427UMxYampfeature=related
McRoberts Maneuvers Video
Multiple Gestationbull Monozygotic (identical) twins can have 1 or 2 placentas
chorions or amnions (uarrrisk if all shared)bull Dizygotic (fraternal) twins 2 of everything
bull Dx faster than usual growth of uterus uarrAFP HCG Ultrasound
bull Risks bull Maternal SAB gestational DM HTNpreeclampsiaHELLP
hydramnios PT labor amp deliverybull Fetal Preterm birth twin-to-twin transfusion
Multiple Gestation (cont)bull Management
bull US to determine what type of twinsbull Prevention of PT laborroutine cervical measurements
(US)bull NST surveillance bull Birth depends on maternal amp fetal complications and
fetal position presentationbull Examination of placentabull Close monitoring PP for hemorrhage (atony)
Abruptio Placentaebull Premature separation of placenta from uterine wallbull SS sharp stabbing pain high in fundus heavy
bleeding (may be occult) hard board-like uterus tense painful uterus signs of shock due to blood loss Port-Wine aminotic fluid if ROM
bull Predisposing fx uarrparity adv maternal age short umbilical cord chronic HTN PIH direct trauma vasoconstriction from cocaine or cigarette use
bull Fetal distress on monitor Can progress to DIC
Abruptio Placentae (cont)bull Management
bull Emergency Immediate c-section if birth not imminent
bull Lg gauge IV bull O2 via mask fetal monitoring
maternal VS lateral positioning labs blood transfusion (have 2 units avail)
bull CBC (HampH) Fibrinogen levels platelet count PTPTT fibrin degradation products ( sx of DIC)
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
for pp hemorrhage
bull Table 26-6 pg 746 differential dx abruptioprevia
Low-lying Marginal
Partial Complete
Placenta Previas
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
Diabetes Pulmonary disease Pregnancy-induced hypertension)
bull Chorioamnionitisbull Suspected fetal problems- Intrauterine Growth
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Inductionbull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessmentbull Bishop Score- rating that determines if the cervix
is ready for induction--Pg 765bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole -Inadequate uterine relaxation between contractions lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveriesbull Forceps
bull Indications unable to push arrested descent need a quick delivery breech
bull Associated with maternalfetal birth trauma rectal sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
laborbull Elective
Placenta Factorsbull Placenta previabull Placental abruptionbull Umbilical cord prolapse
Fetal Factorsbull Breech transverse liebull Macrosomiabull Extreme low birth wtbull Fetal distressbull Fetal anomaliesbull Multiple gestation
Cesarean Birth (cont)bull Mortality
morbiditybull 4 x higher than
vaginal birth in US Most risk assoc with emergency c-section
bull Incisionbull Skin vs uterinebull Classical vs low
transverse
bull Maternal Complicationsbull Infectionbull Anesthesia reactionsbull DeepVeinThrombopheb
itisbull Bleedingbull Ureteralbladder injurybull Increase risk for
subsequent pregnancybull Placenta AcretaPrevia
Infertility
Cesarean Birthbull Pre-op CBC w platelets hold clotbull bicitraantacidbull monitor babybull Teaching pre amp post-op anesthesia recovery
breastfeedingbull Psychosocial issues
bull Fearbull Self-imageself-esteem
Post-Op Carebull Assess fundusbleeding vital signs DVTbull Antibiotics bull Pain Duramorph Breakthrough pain
meds Benadryl for itching Zofran for nausea
bull Clear liquids and advance as toleratedbull Assess for GI function Bowel sounds
Passing flatusbull Ambulation Pre-medicate teach splinting
with pillowbull Stool softener
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
multiparity excessive analgesia Afterpains wwwyoutubecomwatchv=EbItF_7KYCcampfeature=related
Fundal Assessment Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina Cervix returns to firm nongravid consistency
by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum Assessment turn pt to side in Simrsquos
position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments Constipation Give stool softeners as
ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis Superficial leg vein disease
ndash Ss tenderness in portion of vein local heat amp redness normal temperature or low-grade fever
ndash Tx local heat elevate limb bed rest analgesia elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation Engorgement day 3 or 4
ndash If breastfeeding Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
Postpartum Complications Postpartum Hemorrhage
ndash CAUSES Uterine atony lacerations retained placental fragments
Risk factorsndash uarr uterine distension multiples polyhydramnios
macrosomia fibroidsndash Trauma rapid or operative birthndash Placental problems previa accreta abruptio
retained placental fragmentsndash Atonic uterus prolonged pitocin magnesium
sulfate or labor uarr maternal age or parity uterine scar chorioamnionitis anemia prior history
ndash Inadequate blood coagulation fetal death or DIC
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
Which strip shows signs thatImmediate intervention is needed Why What would you do
A
B
Experiences of Painbull Etiology bull Physiologybull Perception
bull Factors influencingAnxiety Psychological factorsExpectations Cultural factorsSupport Fetal position
Comfort and Pain Relief
bull Support from doula or coachbull Alternative therapies
bullRelaxationmassagebull Focusing and imagerybullBreathingbullHerbal preparationsaromatherapybullHypnosis
Comfort and Pain Reliefbull Pharmacological Measures
bullNarcotic analgesicsbullNubainStadolDemerol (pg 689)
bullRegional nerve blocksbullEpiduralspinal
bull Local anesthetic blocksbullPudendalperineal
Systemic AnalgesiaTable 25-3 pg 690
bull Pre-medication Assessment bull Pain level VS allergies drug dependence
(withdrawal) vaginal examprogress in labor UC pattern fetal heart rate tracing
bull Post-medication Assessmentbull VS esp RR LOC dizziness (bedpan)
sedation FHRbull Reversal agent Naloxone (Narcan)
bull Competes with narcotic for opiate receptors Used in both mom and baby (avoid with narcotic dependence)
Regional Anesthesiabull Injection of local anesthesia to block
specific nerve pathwaysbull Epiduralspinal anesthesia
bullSystemic toxicity cardiovascular collapsebullSide effects Hypotension (preload with IV
fluids) fetal distress on FHR tracing spinal HA
bullContradindications coagulation disorders low platelet count (lt 100) allergy neurologic disease aspirin use
bullNursing care Preload IV fluids (LR) monitor BP HR anesthesia level FHR foley cath maternal positioning
Epidural Anesthesia
Medication for Pain Relief Birthbull Local anesthesia
bull Pudendal nerve block (2nd stage episiotomy repair)bull Local infiltration in perineum (episiotomy repair)
bull General anesthesiabull Regional contraindicatedemergencybull Preparation hip wedge preoxygenation cricoid
pressure for intubationbull Complications fetal depression aspiration of
vomitus (Bicitra)
Local anesthesia for Episiotomy
Childbirth at Risk (Ch 26)
Complications of Labor or Delivery
Critical Thinking The client in active labor is requesting pain relief The
physician orders epidural anesthesia for the client Which of the following parameters should the nurse
be prepared to assess immediately after administration of the epidural
bull A) For headache bull B) For urinary retention bull C) The blood pressure bull D) The maternal pulse rate
Precipitous Labor amp Birthbull Labor in lt 3 hoursbull Risk factors
bull Multiparity oxytocin or amniotomy hx of precipitate labor
bull Risks for injurybull Maternal cervical vaginal amp perineal
lacerations with possible hemorrhage pain anxiety
bull Fetal Birth trauma (intracranial bleed brachial palsy) meconium-stained fluid fetal distress
bull Management close monitoring for cervical changes induction
Postterm Pregnancybull gt 42 weeksbull Maternal risks traumahemorrhage due
to larger baby uarroperative deliveryc-section
bull Fetal risks placental changes that darroxygenation to baby and uarrmortality rate oligohydramnios (uarrcord compression during labor) LGA baby (uarrbirth trauma shoulder dystocia) meconium aspiration
bull Management gt 40 wks NST BPP or modified BPP (NST amp AFI) induction
Malpresentationsbull Occiput-posterior (OP)
bull Prolonged labor back labor (sacral nerve compression) arrested dilatation descent perineal tears
bull Usually vaginal but may need C-Section if baby doesnrsquot rotate
bull Management positioning (side-lying knee-chest or hand-knees) sacral pressure during UCrsquos
bull Transverse Liebull Associated with pendulous abdomen uterine
massesfibroids congenital abnormalities of uterus hydramnios
bull Attempt External Cephalic Version if unsuccessful obligatory C-section
Malpresentations (cont)bull Breech presentation
Assessment FHT heard high on the abdomen Leopoldrsquos vaginal exam amp USbull Higher risk of anoxia from prolapsed cord traumatic injury to
the after coming head fracture of spine or arm dysfunctional labor
bull Usually delivered by C-section
External Versionbull External cephalic version (37-38 wks) abdominal
manipulation to change fetal presentationbull Contraindications multiple gestation fetal
breech is engaged in pelvis oligohydramnios nonreactive NST nuchal cord vaginal bleeding IUGR ROM
bull Risks immediate cesarean birthbull Nursing actions NPO 8 hrs NST IV line
terbutaline continuous FHR US used to guide manipulations assess for labor fetal distress O- moms need Rhogam following the procedure
MacrosomiaShoulder Dystociabull Wt gt 4500 gms (9-10 lbs)bull Associated with
bull DM Gestational DM Multiparity Postdates obesitybull Risks
bull Shoulder dystocia difficulty delivering the shoulders after head is delivered (obstetrical emergency)
bull Maternal vaginalcervical tears pp hemorrhage rupturebull Fetal compressed cord fractured clavical asphyxia amp neurologic
damage brachial plexus injury (ErbrsquosPalsy)bull SS Turtle signbull Nursing interventions McRoberts maneuvers suprapubic
pressure PP assess for uterine atonyhemorrhage trauma cerebral or neurologic damage to baby
Video youtubecomwatchv=jV6g427UMxYampfeature=related
McRoberts Maneuvers Video
Multiple Gestationbull Monozygotic (identical) twins can have 1 or 2 placentas
chorions or amnions (uarrrisk if all shared)bull Dizygotic (fraternal) twins 2 of everything
bull Dx faster than usual growth of uterus uarrAFP HCG Ultrasound
bull Risks bull Maternal SAB gestational DM HTNpreeclampsiaHELLP
hydramnios PT labor amp deliverybull Fetal Preterm birth twin-to-twin transfusion
Multiple Gestation (cont)bull Management
bull US to determine what type of twinsbull Prevention of PT laborroutine cervical measurements
(US)bull NST surveillance bull Birth depends on maternal amp fetal complications and
fetal position presentationbull Examination of placentabull Close monitoring PP for hemorrhage (atony)
Abruptio Placentaebull Premature separation of placenta from uterine wallbull SS sharp stabbing pain high in fundus heavy
bleeding (may be occult) hard board-like uterus tense painful uterus signs of shock due to blood loss Port-Wine aminotic fluid if ROM
bull Predisposing fx uarrparity adv maternal age short umbilical cord chronic HTN PIH direct trauma vasoconstriction from cocaine or cigarette use
bull Fetal distress on monitor Can progress to DIC
Abruptio Placentae (cont)bull Management
bull Emergency Immediate c-section if birth not imminent
bull Lg gauge IV bull O2 via mask fetal monitoring
maternal VS lateral positioning labs blood transfusion (have 2 units avail)
bull CBC (HampH) Fibrinogen levels platelet count PTPTT fibrin degradation products ( sx of DIC)
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
for pp hemorrhage
bull Table 26-6 pg 746 differential dx abruptioprevia
Low-lying Marginal
Partial Complete
Placenta Previas
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
Diabetes Pulmonary disease Pregnancy-induced hypertension)
bull Chorioamnionitisbull Suspected fetal problems- Intrauterine Growth
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Inductionbull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessmentbull Bishop Score- rating that determines if the cervix
is ready for induction--Pg 765bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole -Inadequate uterine relaxation between contractions lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveriesbull Forceps
bull Indications unable to push arrested descent need a quick delivery breech
bull Associated with maternalfetal birth trauma rectal sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
laborbull Elective
Placenta Factorsbull Placenta previabull Placental abruptionbull Umbilical cord prolapse
Fetal Factorsbull Breech transverse liebull Macrosomiabull Extreme low birth wtbull Fetal distressbull Fetal anomaliesbull Multiple gestation
Cesarean Birth (cont)bull Mortality
morbiditybull 4 x higher than
vaginal birth in US Most risk assoc with emergency c-section
bull Incisionbull Skin vs uterinebull Classical vs low
transverse
bull Maternal Complicationsbull Infectionbull Anesthesia reactionsbull DeepVeinThrombopheb
itisbull Bleedingbull Ureteralbladder injurybull Increase risk for
subsequent pregnancybull Placenta AcretaPrevia
Infertility
Cesarean Birthbull Pre-op CBC w platelets hold clotbull bicitraantacidbull monitor babybull Teaching pre amp post-op anesthesia recovery
breastfeedingbull Psychosocial issues
bull Fearbull Self-imageself-esteem
Post-Op Carebull Assess fundusbleeding vital signs DVTbull Antibiotics bull Pain Duramorph Breakthrough pain
meds Benadryl for itching Zofran for nausea
bull Clear liquids and advance as toleratedbull Assess for GI function Bowel sounds
Passing flatusbull Ambulation Pre-medicate teach splinting
with pillowbull Stool softener
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
multiparity excessive analgesia Afterpains wwwyoutubecomwatchv=EbItF_7KYCcampfeature=related
Fundal Assessment Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina Cervix returns to firm nongravid consistency
by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum Assessment turn pt to side in Simrsquos
position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments Constipation Give stool softeners as
ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis Superficial leg vein disease
ndash Ss tenderness in portion of vein local heat amp redness normal temperature or low-grade fever
ndash Tx local heat elevate limb bed rest analgesia elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation Engorgement day 3 or 4
ndash If breastfeeding Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
Postpartum Complications Postpartum Hemorrhage
ndash CAUSES Uterine atony lacerations retained placental fragments
Risk factorsndash uarr uterine distension multiples polyhydramnios
macrosomia fibroidsndash Trauma rapid or operative birthndash Placental problems previa accreta abruptio
retained placental fragmentsndash Atonic uterus prolonged pitocin magnesium
sulfate or labor uarr maternal age or parity uterine scar chorioamnionitis anemia prior history
ndash Inadequate blood coagulation fetal death or DIC
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
Experiences of Painbull Etiology bull Physiologybull Perception
bull Factors influencingAnxiety Psychological factorsExpectations Cultural factorsSupport Fetal position
Comfort and Pain Relief
bull Support from doula or coachbull Alternative therapies
bullRelaxationmassagebull Focusing and imagerybullBreathingbullHerbal preparationsaromatherapybullHypnosis
Comfort and Pain Reliefbull Pharmacological Measures
bullNarcotic analgesicsbullNubainStadolDemerol (pg 689)
bullRegional nerve blocksbullEpiduralspinal
bull Local anesthetic blocksbullPudendalperineal
Systemic AnalgesiaTable 25-3 pg 690
bull Pre-medication Assessment bull Pain level VS allergies drug dependence
(withdrawal) vaginal examprogress in labor UC pattern fetal heart rate tracing
bull Post-medication Assessmentbull VS esp RR LOC dizziness (bedpan)
sedation FHRbull Reversal agent Naloxone (Narcan)
bull Competes with narcotic for opiate receptors Used in both mom and baby (avoid with narcotic dependence)
Regional Anesthesiabull Injection of local anesthesia to block
specific nerve pathwaysbull Epiduralspinal anesthesia
bullSystemic toxicity cardiovascular collapsebullSide effects Hypotension (preload with IV
fluids) fetal distress on FHR tracing spinal HA
bullContradindications coagulation disorders low platelet count (lt 100) allergy neurologic disease aspirin use
bullNursing care Preload IV fluids (LR) monitor BP HR anesthesia level FHR foley cath maternal positioning
Epidural Anesthesia
Medication for Pain Relief Birthbull Local anesthesia
bull Pudendal nerve block (2nd stage episiotomy repair)bull Local infiltration in perineum (episiotomy repair)
bull General anesthesiabull Regional contraindicatedemergencybull Preparation hip wedge preoxygenation cricoid
pressure for intubationbull Complications fetal depression aspiration of
vomitus (Bicitra)
Local anesthesia for Episiotomy
Childbirth at Risk (Ch 26)
Complications of Labor or Delivery
Critical Thinking The client in active labor is requesting pain relief The
physician orders epidural anesthesia for the client Which of the following parameters should the nurse
be prepared to assess immediately after administration of the epidural
bull A) For headache bull B) For urinary retention bull C) The blood pressure bull D) The maternal pulse rate
Precipitous Labor amp Birthbull Labor in lt 3 hoursbull Risk factors
bull Multiparity oxytocin or amniotomy hx of precipitate labor
bull Risks for injurybull Maternal cervical vaginal amp perineal
lacerations with possible hemorrhage pain anxiety
bull Fetal Birth trauma (intracranial bleed brachial palsy) meconium-stained fluid fetal distress
bull Management close monitoring for cervical changes induction
Postterm Pregnancybull gt 42 weeksbull Maternal risks traumahemorrhage due
to larger baby uarroperative deliveryc-section
bull Fetal risks placental changes that darroxygenation to baby and uarrmortality rate oligohydramnios (uarrcord compression during labor) LGA baby (uarrbirth trauma shoulder dystocia) meconium aspiration
bull Management gt 40 wks NST BPP or modified BPP (NST amp AFI) induction
Malpresentationsbull Occiput-posterior (OP)
bull Prolonged labor back labor (sacral nerve compression) arrested dilatation descent perineal tears
bull Usually vaginal but may need C-Section if baby doesnrsquot rotate
bull Management positioning (side-lying knee-chest or hand-knees) sacral pressure during UCrsquos
bull Transverse Liebull Associated with pendulous abdomen uterine
massesfibroids congenital abnormalities of uterus hydramnios
bull Attempt External Cephalic Version if unsuccessful obligatory C-section
Malpresentations (cont)bull Breech presentation
Assessment FHT heard high on the abdomen Leopoldrsquos vaginal exam amp USbull Higher risk of anoxia from prolapsed cord traumatic injury to
the after coming head fracture of spine or arm dysfunctional labor
bull Usually delivered by C-section
External Versionbull External cephalic version (37-38 wks) abdominal
manipulation to change fetal presentationbull Contraindications multiple gestation fetal
breech is engaged in pelvis oligohydramnios nonreactive NST nuchal cord vaginal bleeding IUGR ROM
bull Risks immediate cesarean birthbull Nursing actions NPO 8 hrs NST IV line
terbutaline continuous FHR US used to guide manipulations assess for labor fetal distress O- moms need Rhogam following the procedure
MacrosomiaShoulder Dystociabull Wt gt 4500 gms (9-10 lbs)bull Associated with
bull DM Gestational DM Multiparity Postdates obesitybull Risks
bull Shoulder dystocia difficulty delivering the shoulders after head is delivered (obstetrical emergency)
bull Maternal vaginalcervical tears pp hemorrhage rupturebull Fetal compressed cord fractured clavical asphyxia amp neurologic
damage brachial plexus injury (ErbrsquosPalsy)bull SS Turtle signbull Nursing interventions McRoberts maneuvers suprapubic
pressure PP assess for uterine atonyhemorrhage trauma cerebral or neurologic damage to baby
Video youtubecomwatchv=jV6g427UMxYampfeature=related
McRoberts Maneuvers Video
Multiple Gestationbull Monozygotic (identical) twins can have 1 or 2 placentas
chorions or amnions (uarrrisk if all shared)bull Dizygotic (fraternal) twins 2 of everything
bull Dx faster than usual growth of uterus uarrAFP HCG Ultrasound
bull Risks bull Maternal SAB gestational DM HTNpreeclampsiaHELLP
hydramnios PT labor amp deliverybull Fetal Preterm birth twin-to-twin transfusion
Multiple Gestation (cont)bull Management
bull US to determine what type of twinsbull Prevention of PT laborroutine cervical measurements
(US)bull NST surveillance bull Birth depends on maternal amp fetal complications and
fetal position presentationbull Examination of placentabull Close monitoring PP for hemorrhage (atony)
Abruptio Placentaebull Premature separation of placenta from uterine wallbull SS sharp stabbing pain high in fundus heavy
bleeding (may be occult) hard board-like uterus tense painful uterus signs of shock due to blood loss Port-Wine aminotic fluid if ROM
bull Predisposing fx uarrparity adv maternal age short umbilical cord chronic HTN PIH direct trauma vasoconstriction from cocaine or cigarette use
bull Fetal distress on monitor Can progress to DIC
Abruptio Placentae (cont)bull Management
bull Emergency Immediate c-section if birth not imminent
bull Lg gauge IV bull O2 via mask fetal monitoring
maternal VS lateral positioning labs blood transfusion (have 2 units avail)
bull CBC (HampH) Fibrinogen levels platelet count PTPTT fibrin degradation products ( sx of DIC)
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
for pp hemorrhage
bull Table 26-6 pg 746 differential dx abruptioprevia
Low-lying Marginal
Partial Complete
Placenta Previas
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
Diabetes Pulmonary disease Pregnancy-induced hypertension)
bull Chorioamnionitisbull Suspected fetal problems- Intrauterine Growth
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Inductionbull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessmentbull Bishop Score- rating that determines if the cervix
is ready for induction--Pg 765bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole -Inadequate uterine relaxation between contractions lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveriesbull Forceps
bull Indications unable to push arrested descent need a quick delivery breech
bull Associated with maternalfetal birth trauma rectal sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
laborbull Elective
Placenta Factorsbull Placenta previabull Placental abruptionbull Umbilical cord prolapse
Fetal Factorsbull Breech transverse liebull Macrosomiabull Extreme low birth wtbull Fetal distressbull Fetal anomaliesbull Multiple gestation
Cesarean Birth (cont)bull Mortality
morbiditybull 4 x higher than
vaginal birth in US Most risk assoc with emergency c-section
bull Incisionbull Skin vs uterinebull Classical vs low
transverse
bull Maternal Complicationsbull Infectionbull Anesthesia reactionsbull DeepVeinThrombopheb
itisbull Bleedingbull Ureteralbladder injurybull Increase risk for
subsequent pregnancybull Placenta AcretaPrevia
Infertility
Cesarean Birthbull Pre-op CBC w platelets hold clotbull bicitraantacidbull monitor babybull Teaching pre amp post-op anesthesia recovery
breastfeedingbull Psychosocial issues
bull Fearbull Self-imageself-esteem
Post-Op Carebull Assess fundusbleeding vital signs DVTbull Antibiotics bull Pain Duramorph Breakthrough pain
meds Benadryl for itching Zofran for nausea
bull Clear liquids and advance as toleratedbull Assess for GI function Bowel sounds
Passing flatusbull Ambulation Pre-medicate teach splinting
with pillowbull Stool softener
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
multiparity excessive analgesia Afterpains wwwyoutubecomwatchv=EbItF_7KYCcampfeature=related
Fundal Assessment Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina Cervix returns to firm nongravid consistency
by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum Assessment turn pt to side in Simrsquos
position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments Constipation Give stool softeners as
ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis Superficial leg vein disease
ndash Ss tenderness in portion of vein local heat amp redness normal temperature or low-grade fever
ndash Tx local heat elevate limb bed rest analgesia elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation Engorgement day 3 or 4
ndash If breastfeeding Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
Postpartum Complications Postpartum Hemorrhage
ndash CAUSES Uterine atony lacerations retained placental fragments
Risk factorsndash uarr uterine distension multiples polyhydramnios
macrosomia fibroidsndash Trauma rapid or operative birthndash Placental problems previa accreta abruptio
retained placental fragmentsndash Atonic uterus prolonged pitocin magnesium
sulfate or labor uarr maternal age or parity uterine scar chorioamnionitis anemia prior history
ndash Inadequate blood coagulation fetal death or DIC
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
Comfort and Pain Relief
bull Support from doula or coachbull Alternative therapies
bullRelaxationmassagebull Focusing and imagerybullBreathingbullHerbal preparationsaromatherapybullHypnosis
Comfort and Pain Reliefbull Pharmacological Measures
bullNarcotic analgesicsbullNubainStadolDemerol (pg 689)
bullRegional nerve blocksbullEpiduralspinal
bull Local anesthetic blocksbullPudendalperineal
Systemic AnalgesiaTable 25-3 pg 690
bull Pre-medication Assessment bull Pain level VS allergies drug dependence
(withdrawal) vaginal examprogress in labor UC pattern fetal heart rate tracing
bull Post-medication Assessmentbull VS esp RR LOC dizziness (bedpan)
sedation FHRbull Reversal agent Naloxone (Narcan)
bull Competes with narcotic for opiate receptors Used in both mom and baby (avoid with narcotic dependence)
Regional Anesthesiabull Injection of local anesthesia to block
specific nerve pathwaysbull Epiduralspinal anesthesia
bullSystemic toxicity cardiovascular collapsebullSide effects Hypotension (preload with IV
fluids) fetal distress on FHR tracing spinal HA
bullContradindications coagulation disorders low platelet count (lt 100) allergy neurologic disease aspirin use
bullNursing care Preload IV fluids (LR) monitor BP HR anesthesia level FHR foley cath maternal positioning
Epidural Anesthesia
Medication for Pain Relief Birthbull Local anesthesia
bull Pudendal nerve block (2nd stage episiotomy repair)bull Local infiltration in perineum (episiotomy repair)
bull General anesthesiabull Regional contraindicatedemergencybull Preparation hip wedge preoxygenation cricoid
pressure for intubationbull Complications fetal depression aspiration of
vomitus (Bicitra)
Local anesthesia for Episiotomy
Childbirth at Risk (Ch 26)
Complications of Labor or Delivery
Critical Thinking The client in active labor is requesting pain relief The
physician orders epidural anesthesia for the client Which of the following parameters should the nurse
be prepared to assess immediately after administration of the epidural
bull A) For headache bull B) For urinary retention bull C) The blood pressure bull D) The maternal pulse rate
Precipitous Labor amp Birthbull Labor in lt 3 hoursbull Risk factors
bull Multiparity oxytocin or amniotomy hx of precipitate labor
bull Risks for injurybull Maternal cervical vaginal amp perineal
lacerations with possible hemorrhage pain anxiety
bull Fetal Birth trauma (intracranial bleed brachial palsy) meconium-stained fluid fetal distress
bull Management close monitoring for cervical changes induction
Postterm Pregnancybull gt 42 weeksbull Maternal risks traumahemorrhage due
to larger baby uarroperative deliveryc-section
bull Fetal risks placental changes that darroxygenation to baby and uarrmortality rate oligohydramnios (uarrcord compression during labor) LGA baby (uarrbirth trauma shoulder dystocia) meconium aspiration
bull Management gt 40 wks NST BPP or modified BPP (NST amp AFI) induction
Malpresentationsbull Occiput-posterior (OP)
bull Prolonged labor back labor (sacral nerve compression) arrested dilatation descent perineal tears
bull Usually vaginal but may need C-Section if baby doesnrsquot rotate
bull Management positioning (side-lying knee-chest or hand-knees) sacral pressure during UCrsquos
bull Transverse Liebull Associated with pendulous abdomen uterine
massesfibroids congenital abnormalities of uterus hydramnios
bull Attempt External Cephalic Version if unsuccessful obligatory C-section
Malpresentations (cont)bull Breech presentation
Assessment FHT heard high on the abdomen Leopoldrsquos vaginal exam amp USbull Higher risk of anoxia from prolapsed cord traumatic injury to
the after coming head fracture of spine or arm dysfunctional labor
bull Usually delivered by C-section
External Versionbull External cephalic version (37-38 wks) abdominal
manipulation to change fetal presentationbull Contraindications multiple gestation fetal
breech is engaged in pelvis oligohydramnios nonreactive NST nuchal cord vaginal bleeding IUGR ROM
bull Risks immediate cesarean birthbull Nursing actions NPO 8 hrs NST IV line
terbutaline continuous FHR US used to guide manipulations assess for labor fetal distress O- moms need Rhogam following the procedure
MacrosomiaShoulder Dystociabull Wt gt 4500 gms (9-10 lbs)bull Associated with
bull DM Gestational DM Multiparity Postdates obesitybull Risks
bull Shoulder dystocia difficulty delivering the shoulders after head is delivered (obstetrical emergency)
bull Maternal vaginalcervical tears pp hemorrhage rupturebull Fetal compressed cord fractured clavical asphyxia amp neurologic
damage brachial plexus injury (ErbrsquosPalsy)bull SS Turtle signbull Nursing interventions McRoberts maneuvers suprapubic
pressure PP assess for uterine atonyhemorrhage trauma cerebral or neurologic damage to baby
Video youtubecomwatchv=jV6g427UMxYampfeature=related
McRoberts Maneuvers Video
Multiple Gestationbull Monozygotic (identical) twins can have 1 or 2 placentas
chorions or amnions (uarrrisk if all shared)bull Dizygotic (fraternal) twins 2 of everything
bull Dx faster than usual growth of uterus uarrAFP HCG Ultrasound
bull Risks bull Maternal SAB gestational DM HTNpreeclampsiaHELLP
hydramnios PT labor amp deliverybull Fetal Preterm birth twin-to-twin transfusion
Multiple Gestation (cont)bull Management
bull US to determine what type of twinsbull Prevention of PT laborroutine cervical measurements
(US)bull NST surveillance bull Birth depends on maternal amp fetal complications and
fetal position presentationbull Examination of placentabull Close monitoring PP for hemorrhage (atony)
Abruptio Placentaebull Premature separation of placenta from uterine wallbull SS sharp stabbing pain high in fundus heavy
bleeding (may be occult) hard board-like uterus tense painful uterus signs of shock due to blood loss Port-Wine aminotic fluid if ROM
bull Predisposing fx uarrparity adv maternal age short umbilical cord chronic HTN PIH direct trauma vasoconstriction from cocaine or cigarette use
bull Fetal distress on monitor Can progress to DIC
Abruptio Placentae (cont)bull Management
bull Emergency Immediate c-section if birth not imminent
bull Lg gauge IV bull O2 via mask fetal monitoring
maternal VS lateral positioning labs blood transfusion (have 2 units avail)
bull CBC (HampH) Fibrinogen levels platelet count PTPTT fibrin degradation products ( sx of DIC)
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
for pp hemorrhage
bull Table 26-6 pg 746 differential dx abruptioprevia
Low-lying Marginal
Partial Complete
Placenta Previas
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
Diabetes Pulmonary disease Pregnancy-induced hypertension)
bull Chorioamnionitisbull Suspected fetal problems- Intrauterine Growth
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Inductionbull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessmentbull Bishop Score- rating that determines if the cervix
is ready for induction--Pg 765bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole -Inadequate uterine relaxation between contractions lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveriesbull Forceps
bull Indications unable to push arrested descent need a quick delivery breech
bull Associated with maternalfetal birth trauma rectal sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
laborbull Elective
Placenta Factorsbull Placenta previabull Placental abruptionbull Umbilical cord prolapse
Fetal Factorsbull Breech transverse liebull Macrosomiabull Extreme low birth wtbull Fetal distressbull Fetal anomaliesbull Multiple gestation
Cesarean Birth (cont)bull Mortality
morbiditybull 4 x higher than
vaginal birth in US Most risk assoc with emergency c-section
bull Incisionbull Skin vs uterinebull Classical vs low
transverse
bull Maternal Complicationsbull Infectionbull Anesthesia reactionsbull DeepVeinThrombopheb
itisbull Bleedingbull Ureteralbladder injurybull Increase risk for
subsequent pregnancybull Placenta AcretaPrevia
Infertility
Cesarean Birthbull Pre-op CBC w platelets hold clotbull bicitraantacidbull monitor babybull Teaching pre amp post-op anesthesia recovery
breastfeedingbull Psychosocial issues
bull Fearbull Self-imageself-esteem
Post-Op Carebull Assess fundusbleeding vital signs DVTbull Antibiotics bull Pain Duramorph Breakthrough pain
meds Benadryl for itching Zofran for nausea
bull Clear liquids and advance as toleratedbull Assess for GI function Bowel sounds
Passing flatusbull Ambulation Pre-medicate teach splinting
with pillowbull Stool softener
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
multiparity excessive analgesia Afterpains wwwyoutubecomwatchv=EbItF_7KYCcampfeature=related
Fundal Assessment Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina Cervix returns to firm nongravid consistency
by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum Assessment turn pt to side in Simrsquos
position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments Constipation Give stool softeners as
ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis Superficial leg vein disease
ndash Ss tenderness in portion of vein local heat amp redness normal temperature or low-grade fever
ndash Tx local heat elevate limb bed rest analgesia elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation Engorgement day 3 or 4
ndash If breastfeeding Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
Postpartum Complications Postpartum Hemorrhage
ndash CAUSES Uterine atony lacerations retained placental fragments
Risk factorsndash uarr uterine distension multiples polyhydramnios
macrosomia fibroidsndash Trauma rapid or operative birthndash Placental problems previa accreta abruptio
retained placental fragmentsndash Atonic uterus prolonged pitocin magnesium
sulfate or labor uarr maternal age or parity uterine scar chorioamnionitis anemia prior history
ndash Inadequate blood coagulation fetal death or DIC
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
Comfort and Pain Reliefbull Pharmacological Measures
bullNarcotic analgesicsbullNubainStadolDemerol (pg 689)
bullRegional nerve blocksbullEpiduralspinal
bull Local anesthetic blocksbullPudendalperineal
Systemic AnalgesiaTable 25-3 pg 690
bull Pre-medication Assessment bull Pain level VS allergies drug dependence
(withdrawal) vaginal examprogress in labor UC pattern fetal heart rate tracing
bull Post-medication Assessmentbull VS esp RR LOC dizziness (bedpan)
sedation FHRbull Reversal agent Naloxone (Narcan)
bull Competes with narcotic for opiate receptors Used in both mom and baby (avoid with narcotic dependence)
Regional Anesthesiabull Injection of local anesthesia to block
specific nerve pathwaysbull Epiduralspinal anesthesia
bullSystemic toxicity cardiovascular collapsebullSide effects Hypotension (preload with IV
fluids) fetal distress on FHR tracing spinal HA
bullContradindications coagulation disorders low platelet count (lt 100) allergy neurologic disease aspirin use
bullNursing care Preload IV fluids (LR) monitor BP HR anesthesia level FHR foley cath maternal positioning
Epidural Anesthesia
Medication for Pain Relief Birthbull Local anesthesia
bull Pudendal nerve block (2nd stage episiotomy repair)bull Local infiltration in perineum (episiotomy repair)
bull General anesthesiabull Regional contraindicatedemergencybull Preparation hip wedge preoxygenation cricoid
pressure for intubationbull Complications fetal depression aspiration of
vomitus (Bicitra)
Local anesthesia for Episiotomy
Childbirth at Risk (Ch 26)
Complications of Labor or Delivery
Critical Thinking The client in active labor is requesting pain relief The
physician orders epidural anesthesia for the client Which of the following parameters should the nurse
be prepared to assess immediately after administration of the epidural
bull A) For headache bull B) For urinary retention bull C) The blood pressure bull D) The maternal pulse rate
Precipitous Labor amp Birthbull Labor in lt 3 hoursbull Risk factors
bull Multiparity oxytocin or amniotomy hx of precipitate labor
bull Risks for injurybull Maternal cervical vaginal amp perineal
lacerations with possible hemorrhage pain anxiety
bull Fetal Birth trauma (intracranial bleed brachial palsy) meconium-stained fluid fetal distress
bull Management close monitoring for cervical changes induction
Postterm Pregnancybull gt 42 weeksbull Maternal risks traumahemorrhage due
to larger baby uarroperative deliveryc-section
bull Fetal risks placental changes that darroxygenation to baby and uarrmortality rate oligohydramnios (uarrcord compression during labor) LGA baby (uarrbirth trauma shoulder dystocia) meconium aspiration
bull Management gt 40 wks NST BPP or modified BPP (NST amp AFI) induction
Malpresentationsbull Occiput-posterior (OP)
bull Prolonged labor back labor (sacral nerve compression) arrested dilatation descent perineal tears
bull Usually vaginal but may need C-Section if baby doesnrsquot rotate
bull Management positioning (side-lying knee-chest or hand-knees) sacral pressure during UCrsquos
bull Transverse Liebull Associated with pendulous abdomen uterine
massesfibroids congenital abnormalities of uterus hydramnios
bull Attempt External Cephalic Version if unsuccessful obligatory C-section
Malpresentations (cont)bull Breech presentation
Assessment FHT heard high on the abdomen Leopoldrsquos vaginal exam amp USbull Higher risk of anoxia from prolapsed cord traumatic injury to
the after coming head fracture of spine or arm dysfunctional labor
bull Usually delivered by C-section
External Versionbull External cephalic version (37-38 wks) abdominal
manipulation to change fetal presentationbull Contraindications multiple gestation fetal
breech is engaged in pelvis oligohydramnios nonreactive NST nuchal cord vaginal bleeding IUGR ROM
bull Risks immediate cesarean birthbull Nursing actions NPO 8 hrs NST IV line
terbutaline continuous FHR US used to guide manipulations assess for labor fetal distress O- moms need Rhogam following the procedure
MacrosomiaShoulder Dystociabull Wt gt 4500 gms (9-10 lbs)bull Associated with
bull DM Gestational DM Multiparity Postdates obesitybull Risks
bull Shoulder dystocia difficulty delivering the shoulders after head is delivered (obstetrical emergency)
bull Maternal vaginalcervical tears pp hemorrhage rupturebull Fetal compressed cord fractured clavical asphyxia amp neurologic
damage brachial plexus injury (ErbrsquosPalsy)bull SS Turtle signbull Nursing interventions McRoberts maneuvers suprapubic
pressure PP assess for uterine atonyhemorrhage trauma cerebral or neurologic damage to baby
Video youtubecomwatchv=jV6g427UMxYampfeature=related
McRoberts Maneuvers Video
Multiple Gestationbull Monozygotic (identical) twins can have 1 or 2 placentas
chorions or amnions (uarrrisk if all shared)bull Dizygotic (fraternal) twins 2 of everything
bull Dx faster than usual growth of uterus uarrAFP HCG Ultrasound
bull Risks bull Maternal SAB gestational DM HTNpreeclampsiaHELLP
hydramnios PT labor amp deliverybull Fetal Preterm birth twin-to-twin transfusion
Multiple Gestation (cont)bull Management
bull US to determine what type of twinsbull Prevention of PT laborroutine cervical measurements
(US)bull NST surveillance bull Birth depends on maternal amp fetal complications and
fetal position presentationbull Examination of placentabull Close monitoring PP for hemorrhage (atony)
Abruptio Placentaebull Premature separation of placenta from uterine wallbull SS sharp stabbing pain high in fundus heavy
bleeding (may be occult) hard board-like uterus tense painful uterus signs of shock due to blood loss Port-Wine aminotic fluid if ROM
bull Predisposing fx uarrparity adv maternal age short umbilical cord chronic HTN PIH direct trauma vasoconstriction from cocaine or cigarette use
bull Fetal distress on monitor Can progress to DIC
Abruptio Placentae (cont)bull Management
bull Emergency Immediate c-section if birth not imminent
bull Lg gauge IV bull O2 via mask fetal monitoring
maternal VS lateral positioning labs blood transfusion (have 2 units avail)
bull CBC (HampH) Fibrinogen levels platelet count PTPTT fibrin degradation products ( sx of DIC)
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
for pp hemorrhage
bull Table 26-6 pg 746 differential dx abruptioprevia
Low-lying Marginal
Partial Complete
Placenta Previas
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
Diabetes Pulmonary disease Pregnancy-induced hypertension)
bull Chorioamnionitisbull Suspected fetal problems- Intrauterine Growth
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Inductionbull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessmentbull Bishop Score- rating that determines if the cervix
is ready for induction--Pg 765bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole -Inadequate uterine relaxation between contractions lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveriesbull Forceps
bull Indications unable to push arrested descent need a quick delivery breech
bull Associated with maternalfetal birth trauma rectal sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
laborbull Elective
Placenta Factorsbull Placenta previabull Placental abruptionbull Umbilical cord prolapse
Fetal Factorsbull Breech transverse liebull Macrosomiabull Extreme low birth wtbull Fetal distressbull Fetal anomaliesbull Multiple gestation
Cesarean Birth (cont)bull Mortality
morbiditybull 4 x higher than
vaginal birth in US Most risk assoc with emergency c-section
bull Incisionbull Skin vs uterinebull Classical vs low
transverse
bull Maternal Complicationsbull Infectionbull Anesthesia reactionsbull DeepVeinThrombopheb
itisbull Bleedingbull Ureteralbladder injurybull Increase risk for
subsequent pregnancybull Placenta AcretaPrevia
Infertility
Cesarean Birthbull Pre-op CBC w platelets hold clotbull bicitraantacidbull monitor babybull Teaching pre amp post-op anesthesia recovery
breastfeedingbull Psychosocial issues
bull Fearbull Self-imageself-esteem
Post-Op Carebull Assess fundusbleeding vital signs DVTbull Antibiotics bull Pain Duramorph Breakthrough pain
meds Benadryl for itching Zofran for nausea
bull Clear liquids and advance as toleratedbull Assess for GI function Bowel sounds
Passing flatusbull Ambulation Pre-medicate teach splinting
with pillowbull Stool softener
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
multiparity excessive analgesia Afterpains wwwyoutubecomwatchv=EbItF_7KYCcampfeature=related
Fundal Assessment Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina Cervix returns to firm nongravid consistency
by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum Assessment turn pt to side in Simrsquos
position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments Constipation Give stool softeners as
ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis Superficial leg vein disease
ndash Ss tenderness in portion of vein local heat amp redness normal temperature or low-grade fever
ndash Tx local heat elevate limb bed rest analgesia elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation Engorgement day 3 or 4
ndash If breastfeeding Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
Postpartum Complications Postpartum Hemorrhage
ndash CAUSES Uterine atony lacerations retained placental fragments
Risk factorsndash uarr uterine distension multiples polyhydramnios
macrosomia fibroidsndash Trauma rapid or operative birthndash Placental problems previa accreta abruptio
retained placental fragmentsndash Atonic uterus prolonged pitocin magnesium
sulfate or labor uarr maternal age or parity uterine scar chorioamnionitis anemia prior history
ndash Inadequate blood coagulation fetal death or DIC
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
Systemic AnalgesiaTable 25-3 pg 690
bull Pre-medication Assessment bull Pain level VS allergies drug dependence
(withdrawal) vaginal examprogress in labor UC pattern fetal heart rate tracing
bull Post-medication Assessmentbull VS esp RR LOC dizziness (bedpan)
sedation FHRbull Reversal agent Naloxone (Narcan)
bull Competes with narcotic for opiate receptors Used in both mom and baby (avoid with narcotic dependence)
Regional Anesthesiabull Injection of local anesthesia to block
specific nerve pathwaysbull Epiduralspinal anesthesia
bullSystemic toxicity cardiovascular collapsebullSide effects Hypotension (preload with IV
fluids) fetal distress on FHR tracing spinal HA
bullContradindications coagulation disorders low platelet count (lt 100) allergy neurologic disease aspirin use
bullNursing care Preload IV fluids (LR) monitor BP HR anesthesia level FHR foley cath maternal positioning
Epidural Anesthesia
Medication for Pain Relief Birthbull Local anesthesia
bull Pudendal nerve block (2nd stage episiotomy repair)bull Local infiltration in perineum (episiotomy repair)
bull General anesthesiabull Regional contraindicatedemergencybull Preparation hip wedge preoxygenation cricoid
pressure for intubationbull Complications fetal depression aspiration of
vomitus (Bicitra)
Local anesthesia for Episiotomy
Childbirth at Risk (Ch 26)
Complications of Labor or Delivery
Critical Thinking The client in active labor is requesting pain relief The
physician orders epidural anesthesia for the client Which of the following parameters should the nurse
be prepared to assess immediately after administration of the epidural
bull A) For headache bull B) For urinary retention bull C) The blood pressure bull D) The maternal pulse rate
Precipitous Labor amp Birthbull Labor in lt 3 hoursbull Risk factors
bull Multiparity oxytocin or amniotomy hx of precipitate labor
bull Risks for injurybull Maternal cervical vaginal amp perineal
lacerations with possible hemorrhage pain anxiety
bull Fetal Birth trauma (intracranial bleed brachial palsy) meconium-stained fluid fetal distress
bull Management close monitoring for cervical changes induction
Postterm Pregnancybull gt 42 weeksbull Maternal risks traumahemorrhage due
to larger baby uarroperative deliveryc-section
bull Fetal risks placental changes that darroxygenation to baby and uarrmortality rate oligohydramnios (uarrcord compression during labor) LGA baby (uarrbirth trauma shoulder dystocia) meconium aspiration
bull Management gt 40 wks NST BPP or modified BPP (NST amp AFI) induction
Malpresentationsbull Occiput-posterior (OP)
bull Prolonged labor back labor (sacral nerve compression) arrested dilatation descent perineal tears
bull Usually vaginal but may need C-Section if baby doesnrsquot rotate
bull Management positioning (side-lying knee-chest or hand-knees) sacral pressure during UCrsquos
bull Transverse Liebull Associated with pendulous abdomen uterine
massesfibroids congenital abnormalities of uterus hydramnios
bull Attempt External Cephalic Version if unsuccessful obligatory C-section
Malpresentations (cont)bull Breech presentation
Assessment FHT heard high on the abdomen Leopoldrsquos vaginal exam amp USbull Higher risk of anoxia from prolapsed cord traumatic injury to
the after coming head fracture of spine or arm dysfunctional labor
bull Usually delivered by C-section
External Versionbull External cephalic version (37-38 wks) abdominal
manipulation to change fetal presentationbull Contraindications multiple gestation fetal
breech is engaged in pelvis oligohydramnios nonreactive NST nuchal cord vaginal bleeding IUGR ROM
bull Risks immediate cesarean birthbull Nursing actions NPO 8 hrs NST IV line
terbutaline continuous FHR US used to guide manipulations assess for labor fetal distress O- moms need Rhogam following the procedure
MacrosomiaShoulder Dystociabull Wt gt 4500 gms (9-10 lbs)bull Associated with
bull DM Gestational DM Multiparity Postdates obesitybull Risks
bull Shoulder dystocia difficulty delivering the shoulders after head is delivered (obstetrical emergency)
bull Maternal vaginalcervical tears pp hemorrhage rupturebull Fetal compressed cord fractured clavical asphyxia amp neurologic
damage brachial plexus injury (ErbrsquosPalsy)bull SS Turtle signbull Nursing interventions McRoberts maneuvers suprapubic
pressure PP assess for uterine atonyhemorrhage trauma cerebral or neurologic damage to baby
Video youtubecomwatchv=jV6g427UMxYampfeature=related
McRoberts Maneuvers Video
Multiple Gestationbull Monozygotic (identical) twins can have 1 or 2 placentas
chorions or amnions (uarrrisk if all shared)bull Dizygotic (fraternal) twins 2 of everything
bull Dx faster than usual growth of uterus uarrAFP HCG Ultrasound
bull Risks bull Maternal SAB gestational DM HTNpreeclampsiaHELLP
hydramnios PT labor amp deliverybull Fetal Preterm birth twin-to-twin transfusion
Multiple Gestation (cont)bull Management
bull US to determine what type of twinsbull Prevention of PT laborroutine cervical measurements
(US)bull NST surveillance bull Birth depends on maternal amp fetal complications and
fetal position presentationbull Examination of placentabull Close monitoring PP for hemorrhage (atony)
Abruptio Placentaebull Premature separation of placenta from uterine wallbull SS sharp stabbing pain high in fundus heavy
bleeding (may be occult) hard board-like uterus tense painful uterus signs of shock due to blood loss Port-Wine aminotic fluid if ROM
bull Predisposing fx uarrparity adv maternal age short umbilical cord chronic HTN PIH direct trauma vasoconstriction from cocaine or cigarette use
bull Fetal distress on monitor Can progress to DIC
Abruptio Placentae (cont)bull Management
bull Emergency Immediate c-section if birth not imminent
bull Lg gauge IV bull O2 via mask fetal monitoring
maternal VS lateral positioning labs blood transfusion (have 2 units avail)
bull CBC (HampH) Fibrinogen levels platelet count PTPTT fibrin degradation products ( sx of DIC)
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
for pp hemorrhage
bull Table 26-6 pg 746 differential dx abruptioprevia
Low-lying Marginal
Partial Complete
Placenta Previas
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
Diabetes Pulmonary disease Pregnancy-induced hypertension)
bull Chorioamnionitisbull Suspected fetal problems- Intrauterine Growth
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Inductionbull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessmentbull Bishop Score- rating that determines if the cervix
is ready for induction--Pg 765bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole -Inadequate uterine relaxation between contractions lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveriesbull Forceps
bull Indications unable to push arrested descent need a quick delivery breech
bull Associated with maternalfetal birth trauma rectal sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
laborbull Elective
Placenta Factorsbull Placenta previabull Placental abruptionbull Umbilical cord prolapse
Fetal Factorsbull Breech transverse liebull Macrosomiabull Extreme low birth wtbull Fetal distressbull Fetal anomaliesbull Multiple gestation
Cesarean Birth (cont)bull Mortality
morbiditybull 4 x higher than
vaginal birth in US Most risk assoc with emergency c-section
bull Incisionbull Skin vs uterinebull Classical vs low
transverse
bull Maternal Complicationsbull Infectionbull Anesthesia reactionsbull DeepVeinThrombopheb
itisbull Bleedingbull Ureteralbladder injurybull Increase risk for
subsequent pregnancybull Placenta AcretaPrevia
Infertility
Cesarean Birthbull Pre-op CBC w platelets hold clotbull bicitraantacidbull monitor babybull Teaching pre amp post-op anesthesia recovery
breastfeedingbull Psychosocial issues
bull Fearbull Self-imageself-esteem
Post-Op Carebull Assess fundusbleeding vital signs DVTbull Antibiotics bull Pain Duramorph Breakthrough pain
meds Benadryl for itching Zofran for nausea
bull Clear liquids and advance as toleratedbull Assess for GI function Bowel sounds
Passing flatusbull Ambulation Pre-medicate teach splinting
with pillowbull Stool softener
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
multiparity excessive analgesia Afterpains wwwyoutubecomwatchv=EbItF_7KYCcampfeature=related
Fundal Assessment Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina Cervix returns to firm nongravid consistency
by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum Assessment turn pt to side in Simrsquos
position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments Constipation Give stool softeners as
ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis Superficial leg vein disease
ndash Ss tenderness in portion of vein local heat amp redness normal temperature or low-grade fever
ndash Tx local heat elevate limb bed rest analgesia elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation Engorgement day 3 or 4
ndash If breastfeeding Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
Postpartum Complications Postpartum Hemorrhage
ndash CAUSES Uterine atony lacerations retained placental fragments
Risk factorsndash uarr uterine distension multiples polyhydramnios
macrosomia fibroidsndash Trauma rapid or operative birthndash Placental problems previa accreta abruptio
retained placental fragmentsndash Atonic uterus prolonged pitocin magnesium
sulfate or labor uarr maternal age or parity uterine scar chorioamnionitis anemia prior history
ndash Inadequate blood coagulation fetal death or DIC
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
Regional Anesthesiabull Injection of local anesthesia to block
specific nerve pathwaysbull Epiduralspinal anesthesia
bullSystemic toxicity cardiovascular collapsebullSide effects Hypotension (preload with IV
fluids) fetal distress on FHR tracing spinal HA
bullContradindications coagulation disorders low platelet count (lt 100) allergy neurologic disease aspirin use
bullNursing care Preload IV fluids (LR) monitor BP HR anesthesia level FHR foley cath maternal positioning
Epidural Anesthesia
Medication for Pain Relief Birthbull Local anesthesia
bull Pudendal nerve block (2nd stage episiotomy repair)bull Local infiltration in perineum (episiotomy repair)
bull General anesthesiabull Regional contraindicatedemergencybull Preparation hip wedge preoxygenation cricoid
pressure for intubationbull Complications fetal depression aspiration of
vomitus (Bicitra)
Local anesthesia for Episiotomy
Childbirth at Risk (Ch 26)
Complications of Labor or Delivery
Critical Thinking The client in active labor is requesting pain relief The
physician orders epidural anesthesia for the client Which of the following parameters should the nurse
be prepared to assess immediately after administration of the epidural
bull A) For headache bull B) For urinary retention bull C) The blood pressure bull D) The maternal pulse rate
Precipitous Labor amp Birthbull Labor in lt 3 hoursbull Risk factors
bull Multiparity oxytocin or amniotomy hx of precipitate labor
bull Risks for injurybull Maternal cervical vaginal amp perineal
lacerations with possible hemorrhage pain anxiety
bull Fetal Birth trauma (intracranial bleed brachial palsy) meconium-stained fluid fetal distress
bull Management close monitoring for cervical changes induction
Postterm Pregnancybull gt 42 weeksbull Maternal risks traumahemorrhage due
to larger baby uarroperative deliveryc-section
bull Fetal risks placental changes that darroxygenation to baby and uarrmortality rate oligohydramnios (uarrcord compression during labor) LGA baby (uarrbirth trauma shoulder dystocia) meconium aspiration
bull Management gt 40 wks NST BPP or modified BPP (NST amp AFI) induction
Malpresentationsbull Occiput-posterior (OP)
bull Prolonged labor back labor (sacral nerve compression) arrested dilatation descent perineal tears
bull Usually vaginal but may need C-Section if baby doesnrsquot rotate
bull Management positioning (side-lying knee-chest or hand-knees) sacral pressure during UCrsquos
bull Transverse Liebull Associated with pendulous abdomen uterine
massesfibroids congenital abnormalities of uterus hydramnios
bull Attempt External Cephalic Version if unsuccessful obligatory C-section
Malpresentations (cont)bull Breech presentation
Assessment FHT heard high on the abdomen Leopoldrsquos vaginal exam amp USbull Higher risk of anoxia from prolapsed cord traumatic injury to
the after coming head fracture of spine or arm dysfunctional labor
bull Usually delivered by C-section
External Versionbull External cephalic version (37-38 wks) abdominal
manipulation to change fetal presentationbull Contraindications multiple gestation fetal
breech is engaged in pelvis oligohydramnios nonreactive NST nuchal cord vaginal bleeding IUGR ROM
bull Risks immediate cesarean birthbull Nursing actions NPO 8 hrs NST IV line
terbutaline continuous FHR US used to guide manipulations assess for labor fetal distress O- moms need Rhogam following the procedure
MacrosomiaShoulder Dystociabull Wt gt 4500 gms (9-10 lbs)bull Associated with
bull DM Gestational DM Multiparity Postdates obesitybull Risks
bull Shoulder dystocia difficulty delivering the shoulders after head is delivered (obstetrical emergency)
bull Maternal vaginalcervical tears pp hemorrhage rupturebull Fetal compressed cord fractured clavical asphyxia amp neurologic
damage brachial plexus injury (ErbrsquosPalsy)bull SS Turtle signbull Nursing interventions McRoberts maneuvers suprapubic
pressure PP assess for uterine atonyhemorrhage trauma cerebral or neurologic damage to baby
Video youtubecomwatchv=jV6g427UMxYampfeature=related
McRoberts Maneuvers Video
Multiple Gestationbull Monozygotic (identical) twins can have 1 or 2 placentas
chorions or amnions (uarrrisk if all shared)bull Dizygotic (fraternal) twins 2 of everything
bull Dx faster than usual growth of uterus uarrAFP HCG Ultrasound
bull Risks bull Maternal SAB gestational DM HTNpreeclampsiaHELLP
hydramnios PT labor amp deliverybull Fetal Preterm birth twin-to-twin transfusion
Multiple Gestation (cont)bull Management
bull US to determine what type of twinsbull Prevention of PT laborroutine cervical measurements
(US)bull NST surveillance bull Birth depends on maternal amp fetal complications and
fetal position presentationbull Examination of placentabull Close monitoring PP for hemorrhage (atony)
Abruptio Placentaebull Premature separation of placenta from uterine wallbull SS sharp stabbing pain high in fundus heavy
bleeding (may be occult) hard board-like uterus tense painful uterus signs of shock due to blood loss Port-Wine aminotic fluid if ROM
bull Predisposing fx uarrparity adv maternal age short umbilical cord chronic HTN PIH direct trauma vasoconstriction from cocaine or cigarette use
bull Fetal distress on monitor Can progress to DIC
Abruptio Placentae (cont)bull Management
bull Emergency Immediate c-section if birth not imminent
bull Lg gauge IV bull O2 via mask fetal monitoring
maternal VS lateral positioning labs blood transfusion (have 2 units avail)
bull CBC (HampH) Fibrinogen levels platelet count PTPTT fibrin degradation products ( sx of DIC)
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
for pp hemorrhage
bull Table 26-6 pg 746 differential dx abruptioprevia
Low-lying Marginal
Partial Complete
Placenta Previas
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
Diabetes Pulmonary disease Pregnancy-induced hypertension)
bull Chorioamnionitisbull Suspected fetal problems- Intrauterine Growth
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Inductionbull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessmentbull Bishop Score- rating that determines if the cervix
is ready for induction--Pg 765bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole -Inadequate uterine relaxation between contractions lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveriesbull Forceps
bull Indications unable to push arrested descent need a quick delivery breech
bull Associated with maternalfetal birth trauma rectal sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
laborbull Elective
Placenta Factorsbull Placenta previabull Placental abruptionbull Umbilical cord prolapse
Fetal Factorsbull Breech transverse liebull Macrosomiabull Extreme low birth wtbull Fetal distressbull Fetal anomaliesbull Multiple gestation
Cesarean Birth (cont)bull Mortality
morbiditybull 4 x higher than
vaginal birth in US Most risk assoc with emergency c-section
bull Incisionbull Skin vs uterinebull Classical vs low
transverse
bull Maternal Complicationsbull Infectionbull Anesthesia reactionsbull DeepVeinThrombopheb
itisbull Bleedingbull Ureteralbladder injurybull Increase risk for
subsequent pregnancybull Placenta AcretaPrevia
Infertility
Cesarean Birthbull Pre-op CBC w platelets hold clotbull bicitraantacidbull monitor babybull Teaching pre amp post-op anesthesia recovery
breastfeedingbull Psychosocial issues
bull Fearbull Self-imageself-esteem
Post-Op Carebull Assess fundusbleeding vital signs DVTbull Antibiotics bull Pain Duramorph Breakthrough pain
meds Benadryl for itching Zofran for nausea
bull Clear liquids and advance as toleratedbull Assess for GI function Bowel sounds
Passing flatusbull Ambulation Pre-medicate teach splinting
with pillowbull Stool softener
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
multiparity excessive analgesia Afterpains wwwyoutubecomwatchv=EbItF_7KYCcampfeature=related
Fundal Assessment Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina Cervix returns to firm nongravid consistency
by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum Assessment turn pt to side in Simrsquos
position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments Constipation Give stool softeners as
ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis Superficial leg vein disease
ndash Ss tenderness in portion of vein local heat amp redness normal temperature or low-grade fever
ndash Tx local heat elevate limb bed rest analgesia elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation Engorgement day 3 or 4
ndash If breastfeeding Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
Postpartum Complications Postpartum Hemorrhage
ndash CAUSES Uterine atony lacerations retained placental fragments
Risk factorsndash uarr uterine distension multiples polyhydramnios
macrosomia fibroidsndash Trauma rapid or operative birthndash Placental problems previa accreta abruptio
retained placental fragmentsndash Atonic uterus prolonged pitocin magnesium
sulfate or labor uarr maternal age or parity uterine scar chorioamnionitis anemia prior history
ndash Inadequate blood coagulation fetal death or DIC
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
Epidural Anesthesia
Medication for Pain Relief Birthbull Local anesthesia
bull Pudendal nerve block (2nd stage episiotomy repair)bull Local infiltration in perineum (episiotomy repair)
bull General anesthesiabull Regional contraindicatedemergencybull Preparation hip wedge preoxygenation cricoid
pressure for intubationbull Complications fetal depression aspiration of
vomitus (Bicitra)
Local anesthesia for Episiotomy
Childbirth at Risk (Ch 26)
Complications of Labor or Delivery
Critical Thinking The client in active labor is requesting pain relief The
physician orders epidural anesthesia for the client Which of the following parameters should the nurse
be prepared to assess immediately after administration of the epidural
bull A) For headache bull B) For urinary retention bull C) The blood pressure bull D) The maternal pulse rate
Precipitous Labor amp Birthbull Labor in lt 3 hoursbull Risk factors
bull Multiparity oxytocin or amniotomy hx of precipitate labor
bull Risks for injurybull Maternal cervical vaginal amp perineal
lacerations with possible hemorrhage pain anxiety
bull Fetal Birth trauma (intracranial bleed brachial palsy) meconium-stained fluid fetal distress
bull Management close monitoring for cervical changes induction
Postterm Pregnancybull gt 42 weeksbull Maternal risks traumahemorrhage due
to larger baby uarroperative deliveryc-section
bull Fetal risks placental changes that darroxygenation to baby and uarrmortality rate oligohydramnios (uarrcord compression during labor) LGA baby (uarrbirth trauma shoulder dystocia) meconium aspiration
bull Management gt 40 wks NST BPP or modified BPP (NST amp AFI) induction
Malpresentationsbull Occiput-posterior (OP)
bull Prolonged labor back labor (sacral nerve compression) arrested dilatation descent perineal tears
bull Usually vaginal but may need C-Section if baby doesnrsquot rotate
bull Management positioning (side-lying knee-chest or hand-knees) sacral pressure during UCrsquos
bull Transverse Liebull Associated with pendulous abdomen uterine
massesfibroids congenital abnormalities of uterus hydramnios
bull Attempt External Cephalic Version if unsuccessful obligatory C-section
Malpresentations (cont)bull Breech presentation
Assessment FHT heard high on the abdomen Leopoldrsquos vaginal exam amp USbull Higher risk of anoxia from prolapsed cord traumatic injury to
the after coming head fracture of spine or arm dysfunctional labor
bull Usually delivered by C-section
External Versionbull External cephalic version (37-38 wks) abdominal
manipulation to change fetal presentationbull Contraindications multiple gestation fetal
breech is engaged in pelvis oligohydramnios nonreactive NST nuchal cord vaginal bleeding IUGR ROM
bull Risks immediate cesarean birthbull Nursing actions NPO 8 hrs NST IV line
terbutaline continuous FHR US used to guide manipulations assess for labor fetal distress O- moms need Rhogam following the procedure
MacrosomiaShoulder Dystociabull Wt gt 4500 gms (9-10 lbs)bull Associated with
bull DM Gestational DM Multiparity Postdates obesitybull Risks
bull Shoulder dystocia difficulty delivering the shoulders after head is delivered (obstetrical emergency)
bull Maternal vaginalcervical tears pp hemorrhage rupturebull Fetal compressed cord fractured clavical asphyxia amp neurologic
damage brachial plexus injury (ErbrsquosPalsy)bull SS Turtle signbull Nursing interventions McRoberts maneuvers suprapubic
pressure PP assess for uterine atonyhemorrhage trauma cerebral or neurologic damage to baby
Video youtubecomwatchv=jV6g427UMxYampfeature=related
McRoberts Maneuvers Video
Multiple Gestationbull Monozygotic (identical) twins can have 1 or 2 placentas
chorions or amnions (uarrrisk if all shared)bull Dizygotic (fraternal) twins 2 of everything
bull Dx faster than usual growth of uterus uarrAFP HCG Ultrasound
bull Risks bull Maternal SAB gestational DM HTNpreeclampsiaHELLP
hydramnios PT labor amp deliverybull Fetal Preterm birth twin-to-twin transfusion
Multiple Gestation (cont)bull Management
bull US to determine what type of twinsbull Prevention of PT laborroutine cervical measurements
(US)bull NST surveillance bull Birth depends on maternal amp fetal complications and
fetal position presentationbull Examination of placentabull Close monitoring PP for hemorrhage (atony)
Abruptio Placentaebull Premature separation of placenta from uterine wallbull SS sharp stabbing pain high in fundus heavy
bleeding (may be occult) hard board-like uterus tense painful uterus signs of shock due to blood loss Port-Wine aminotic fluid if ROM
bull Predisposing fx uarrparity adv maternal age short umbilical cord chronic HTN PIH direct trauma vasoconstriction from cocaine or cigarette use
bull Fetal distress on monitor Can progress to DIC
Abruptio Placentae (cont)bull Management
bull Emergency Immediate c-section if birth not imminent
bull Lg gauge IV bull O2 via mask fetal monitoring
maternal VS lateral positioning labs blood transfusion (have 2 units avail)
bull CBC (HampH) Fibrinogen levels platelet count PTPTT fibrin degradation products ( sx of DIC)
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
for pp hemorrhage
bull Table 26-6 pg 746 differential dx abruptioprevia
Low-lying Marginal
Partial Complete
Placenta Previas
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
Diabetes Pulmonary disease Pregnancy-induced hypertension)
bull Chorioamnionitisbull Suspected fetal problems- Intrauterine Growth
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Inductionbull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessmentbull Bishop Score- rating that determines if the cervix
is ready for induction--Pg 765bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole -Inadequate uterine relaxation between contractions lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveriesbull Forceps
bull Indications unable to push arrested descent need a quick delivery breech
bull Associated with maternalfetal birth trauma rectal sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
laborbull Elective
Placenta Factorsbull Placenta previabull Placental abruptionbull Umbilical cord prolapse
Fetal Factorsbull Breech transverse liebull Macrosomiabull Extreme low birth wtbull Fetal distressbull Fetal anomaliesbull Multiple gestation
Cesarean Birth (cont)bull Mortality
morbiditybull 4 x higher than
vaginal birth in US Most risk assoc with emergency c-section
bull Incisionbull Skin vs uterinebull Classical vs low
transverse
bull Maternal Complicationsbull Infectionbull Anesthesia reactionsbull DeepVeinThrombopheb
itisbull Bleedingbull Ureteralbladder injurybull Increase risk for
subsequent pregnancybull Placenta AcretaPrevia
Infertility
Cesarean Birthbull Pre-op CBC w platelets hold clotbull bicitraantacidbull monitor babybull Teaching pre amp post-op anesthesia recovery
breastfeedingbull Psychosocial issues
bull Fearbull Self-imageself-esteem
Post-Op Carebull Assess fundusbleeding vital signs DVTbull Antibiotics bull Pain Duramorph Breakthrough pain
meds Benadryl for itching Zofran for nausea
bull Clear liquids and advance as toleratedbull Assess for GI function Bowel sounds
Passing flatusbull Ambulation Pre-medicate teach splinting
with pillowbull Stool softener
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
multiparity excessive analgesia Afterpains wwwyoutubecomwatchv=EbItF_7KYCcampfeature=related
Fundal Assessment Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina Cervix returns to firm nongravid consistency
by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum Assessment turn pt to side in Simrsquos
position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments Constipation Give stool softeners as
ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis Superficial leg vein disease
ndash Ss tenderness in portion of vein local heat amp redness normal temperature or low-grade fever
ndash Tx local heat elevate limb bed rest analgesia elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation Engorgement day 3 or 4
ndash If breastfeeding Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
Postpartum Complications Postpartum Hemorrhage
ndash CAUSES Uterine atony lacerations retained placental fragments
Risk factorsndash uarr uterine distension multiples polyhydramnios
macrosomia fibroidsndash Trauma rapid or operative birthndash Placental problems previa accreta abruptio
retained placental fragmentsndash Atonic uterus prolonged pitocin magnesium
sulfate or labor uarr maternal age or parity uterine scar chorioamnionitis anemia prior history
ndash Inadequate blood coagulation fetal death or DIC
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
Medication for Pain Relief Birthbull Local anesthesia
bull Pudendal nerve block (2nd stage episiotomy repair)bull Local infiltration in perineum (episiotomy repair)
bull General anesthesiabull Regional contraindicatedemergencybull Preparation hip wedge preoxygenation cricoid
pressure for intubationbull Complications fetal depression aspiration of
vomitus (Bicitra)
Local anesthesia for Episiotomy
Childbirth at Risk (Ch 26)
Complications of Labor or Delivery
Critical Thinking The client in active labor is requesting pain relief The
physician orders epidural anesthesia for the client Which of the following parameters should the nurse
be prepared to assess immediately after administration of the epidural
bull A) For headache bull B) For urinary retention bull C) The blood pressure bull D) The maternal pulse rate
Precipitous Labor amp Birthbull Labor in lt 3 hoursbull Risk factors
bull Multiparity oxytocin or amniotomy hx of precipitate labor
bull Risks for injurybull Maternal cervical vaginal amp perineal
lacerations with possible hemorrhage pain anxiety
bull Fetal Birth trauma (intracranial bleed brachial palsy) meconium-stained fluid fetal distress
bull Management close monitoring for cervical changes induction
Postterm Pregnancybull gt 42 weeksbull Maternal risks traumahemorrhage due
to larger baby uarroperative deliveryc-section
bull Fetal risks placental changes that darroxygenation to baby and uarrmortality rate oligohydramnios (uarrcord compression during labor) LGA baby (uarrbirth trauma shoulder dystocia) meconium aspiration
bull Management gt 40 wks NST BPP or modified BPP (NST amp AFI) induction
Malpresentationsbull Occiput-posterior (OP)
bull Prolonged labor back labor (sacral nerve compression) arrested dilatation descent perineal tears
bull Usually vaginal but may need C-Section if baby doesnrsquot rotate
bull Management positioning (side-lying knee-chest or hand-knees) sacral pressure during UCrsquos
bull Transverse Liebull Associated with pendulous abdomen uterine
massesfibroids congenital abnormalities of uterus hydramnios
bull Attempt External Cephalic Version if unsuccessful obligatory C-section
Malpresentations (cont)bull Breech presentation
Assessment FHT heard high on the abdomen Leopoldrsquos vaginal exam amp USbull Higher risk of anoxia from prolapsed cord traumatic injury to
the after coming head fracture of spine or arm dysfunctional labor
bull Usually delivered by C-section
External Versionbull External cephalic version (37-38 wks) abdominal
manipulation to change fetal presentationbull Contraindications multiple gestation fetal
breech is engaged in pelvis oligohydramnios nonreactive NST nuchal cord vaginal bleeding IUGR ROM
bull Risks immediate cesarean birthbull Nursing actions NPO 8 hrs NST IV line
terbutaline continuous FHR US used to guide manipulations assess for labor fetal distress O- moms need Rhogam following the procedure
MacrosomiaShoulder Dystociabull Wt gt 4500 gms (9-10 lbs)bull Associated with
bull DM Gestational DM Multiparity Postdates obesitybull Risks
bull Shoulder dystocia difficulty delivering the shoulders after head is delivered (obstetrical emergency)
bull Maternal vaginalcervical tears pp hemorrhage rupturebull Fetal compressed cord fractured clavical asphyxia amp neurologic
damage brachial plexus injury (ErbrsquosPalsy)bull SS Turtle signbull Nursing interventions McRoberts maneuvers suprapubic
pressure PP assess for uterine atonyhemorrhage trauma cerebral or neurologic damage to baby
Video youtubecomwatchv=jV6g427UMxYampfeature=related
McRoberts Maneuvers Video
Multiple Gestationbull Monozygotic (identical) twins can have 1 or 2 placentas
chorions or amnions (uarrrisk if all shared)bull Dizygotic (fraternal) twins 2 of everything
bull Dx faster than usual growth of uterus uarrAFP HCG Ultrasound
bull Risks bull Maternal SAB gestational DM HTNpreeclampsiaHELLP
hydramnios PT labor amp deliverybull Fetal Preterm birth twin-to-twin transfusion
Multiple Gestation (cont)bull Management
bull US to determine what type of twinsbull Prevention of PT laborroutine cervical measurements
(US)bull NST surveillance bull Birth depends on maternal amp fetal complications and
fetal position presentationbull Examination of placentabull Close monitoring PP for hemorrhage (atony)
Abruptio Placentaebull Premature separation of placenta from uterine wallbull SS sharp stabbing pain high in fundus heavy
bleeding (may be occult) hard board-like uterus tense painful uterus signs of shock due to blood loss Port-Wine aminotic fluid if ROM
bull Predisposing fx uarrparity adv maternal age short umbilical cord chronic HTN PIH direct trauma vasoconstriction from cocaine or cigarette use
bull Fetal distress on monitor Can progress to DIC
Abruptio Placentae (cont)bull Management
bull Emergency Immediate c-section if birth not imminent
bull Lg gauge IV bull O2 via mask fetal monitoring
maternal VS lateral positioning labs blood transfusion (have 2 units avail)
bull CBC (HampH) Fibrinogen levels platelet count PTPTT fibrin degradation products ( sx of DIC)
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
for pp hemorrhage
bull Table 26-6 pg 746 differential dx abruptioprevia
Low-lying Marginal
Partial Complete
Placenta Previas
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
Diabetes Pulmonary disease Pregnancy-induced hypertension)
bull Chorioamnionitisbull Suspected fetal problems- Intrauterine Growth
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Inductionbull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessmentbull Bishop Score- rating that determines if the cervix
is ready for induction--Pg 765bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole -Inadequate uterine relaxation between contractions lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveriesbull Forceps
bull Indications unable to push arrested descent need a quick delivery breech
bull Associated with maternalfetal birth trauma rectal sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
laborbull Elective
Placenta Factorsbull Placenta previabull Placental abruptionbull Umbilical cord prolapse
Fetal Factorsbull Breech transverse liebull Macrosomiabull Extreme low birth wtbull Fetal distressbull Fetal anomaliesbull Multiple gestation
Cesarean Birth (cont)bull Mortality
morbiditybull 4 x higher than
vaginal birth in US Most risk assoc with emergency c-section
bull Incisionbull Skin vs uterinebull Classical vs low
transverse
bull Maternal Complicationsbull Infectionbull Anesthesia reactionsbull DeepVeinThrombopheb
itisbull Bleedingbull Ureteralbladder injurybull Increase risk for
subsequent pregnancybull Placenta AcretaPrevia
Infertility
Cesarean Birthbull Pre-op CBC w platelets hold clotbull bicitraantacidbull monitor babybull Teaching pre amp post-op anesthesia recovery
breastfeedingbull Psychosocial issues
bull Fearbull Self-imageself-esteem
Post-Op Carebull Assess fundusbleeding vital signs DVTbull Antibiotics bull Pain Duramorph Breakthrough pain
meds Benadryl for itching Zofran for nausea
bull Clear liquids and advance as toleratedbull Assess for GI function Bowel sounds
Passing flatusbull Ambulation Pre-medicate teach splinting
with pillowbull Stool softener
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
multiparity excessive analgesia Afterpains wwwyoutubecomwatchv=EbItF_7KYCcampfeature=related
Fundal Assessment Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina Cervix returns to firm nongravid consistency
by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum Assessment turn pt to side in Simrsquos
position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments Constipation Give stool softeners as
ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis Superficial leg vein disease
ndash Ss tenderness in portion of vein local heat amp redness normal temperature or low-grade fever
ndash Tx local heat elevate limb bed rest analgesia elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation Engorgement day 3 or 4
ndash If breastfeeding Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
Postpartum Complications Postpartum Hemorrhage
ndash CAUSES Uterine atony lacerations retained placental fragments
Risk factorsndash uarr uterine distension multiples polyhydramnios
macrosomia fibroidsndash Trauma rapid or operative birthndash Placental problems previa accreta abruptio
retained placental fragmentsndash Atonic uterus prolonged pitocin magnesium
sulfate or labor uarr maternal age or parity uterine scar chorioamnionitis anemia prior history
ndash Inadequate blood coagulation fetal death or DIC
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
Local anesthesia for Episiotomy
Childbirth at Risk (Ch 26)
Complications of Labor or Delivery
Critical Thinking The client in active labor is requesting pain relief The
physician orders epidural anesthesia for the client Which of the following parameters should the nurse
be prepared to assess immediately after administration of the epidural
bull A) For headache bull B) For urinary retention bull C) The blood pressure bull D) The maternal pulse rate
Precipitous Labor amp Birthbull Labor in lt 3 hoursbull Risk factors
bull Multiparity oxytocin or amniotomy hx of precipitate labor
bull Risks for injurybull Maternal cervical vaginal amp perineal
lacerations with possible hemorrhage pain anxiety
bull Fetal Birth trauma (intracranial bleed brachial palsy) meconium-stained fluid fetal distress
bull Management close monitoring for cervical changes induction
Postterm Pregnancybull gt 42 weeksbull Maternal risks traumahemorrhage due
to larger baby uarroperative deliveryc-section
bull Fetal risks placental changes that darroxygenation to baby and uarrmortality rate oligohydramnios (uarrcord compression during labor) LGA baby (uarrbirth trauma shoulder dystocia) meconium aspiration
bull Management gt 40 wks NST BPP or modified BPP (NST amp AFI) induction
Malpresentationsbull Occiput-posterior (OP)
bull Prolonged labor back labor (sacral nerve compression) arrested dilatation descent perineal tears
bull Usually vaginal but may need C-Section if baby doesnrsquot rotate
bull Management positioning (side-lying knee-chest or hand-knees) sacral pressure during UCrsquos
bull Transverse Liebull Associated with pendulous abdomen uterine
massesfibroids congenital abnormalities of uterus hydramnios
bull Attempt External Cephalic Version if unsuccessful obligatory C-section
Malpresentations (cont)bull Breech presentation
Assessment FHT heard high on the abdomen Leopoldrsquos vaginal exam amp USbull Higher risk of anoxia from prolapsed cord traumatic injury to
the after coming head fracture of spine or arm dysfunctional labor
bull Usually delivered by C-section
External Versionbull External cephalic version (37-38 wks) abdominal
manipulation to change fetal presentationbull Contraindications multiple gestation fetal
breech is engaged in pelvis oligohydramnios nonreactive NST nuchal cord vaginal bleeding IUGR ROM
bull Risks immediate cesarean birthbull Nursing actions NPO 8 hrs NST IV line
terbutaline continuous FHR US used to guide manipulations assess for labor fetal distress O- moms need Rhogam following the procedure
MacrosomiaShoulder Dystociabull Wt gt 4500 gms (9-10 lbs)bull Associated with
bull DM Gestational DM Multiparity Postdates obesitybull Risks
bull Shoulder dystocia difficulty delivering the shoulders after head is delivered (obstetrical emergency)
bull Maternal vaginalcervical tears pp hemorrhage rupturebull Fetal compressed cord fractured clavical asphyxia amp neurologic
damage brachial plexus injury (ErbrsquosPalsy)bull SS Turtle signbull Nursing interventions McRoberts maneuvers suprapubic
pressure PP assess for uterine atonyhemorrhage trauma cerebral or neurologic damage to baby
Video youtubecomwatchv=jV6g427UMxYampfeature=related
McRoberts Maneuvers Video
Multiple Gestationbull Monozygotic (identical) twins can have 1 or 2 placentas
chorions or amnions (uarrrisk if all shared)bull Dizygotic (fraternal) twins 2 of everything
bull Dx faster than usual growth of uterus uarrAFP HCG Ultrasound
bull Risks bull Maternal SAB gestational DM HTNpreeclampsiaHELLP
hydramnios PT labor amp deliverybull Fetal Preterm birth twin-to-twin transfusion
Multiple Gestation (cont)bull Management
bull US to determine what type of twinsbull Prevention of PT laborroutine cervical measurements
(US)bull NST surveillance bull Birth depends on maternal amp fetal complications and
fetal position presentationbull Examination of placentabull Close monitoring PP for hemorrhage (atony)
Abruptio Placentaebull Premature separation of placenta from uterine wallbull SS sharp stabbing pain high in fundus heavy
bleeding (may be occult) hard board-like uterus tense painful uterus signs of shock due to blood loss Port-Wine aminotic fluid if ROM
bull Predisposing fx uarrparity adv maternal age short umbilical cord chronic HTN PIH direct trauma vasoconstriction from cocaine or cigarette use
bull Fetal distress on monitor Can progress to DIC
Abruptio Placentae (cont)bull Management
bull Emergency Immediate c-section if birth not imminent
bull Lg gauge IV bull O2 via mask fetal monitoring
maternal VS lateral positioning labs blood transfusion (have 2 units avail)
bull CBC (HampH) Fibrinogen levels platelet count PTPTT fibrin degradation products ( sx of DIC)
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
for pp hemorrhage
bull Table 26-6 pg 746 differential dx abruptioprevia
Low-lying Marginal
Partial Complete
Placenta Previas
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
Diabetes Pulmonary disease Pregnancy-induced hypertension)
bull Chorioamnionitisbull Suspected fetal problems- Intrauterine Growth
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Inductionbull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessmentbull Bishop Score- rating that determines if the cervix
is ready for induction--Pg 765bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole -Inadequate uterine relaxation between contractions lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveriesbull Forceps
bull Indications unable to push arrested descent need a quick delivery breech
bull Associated with maternalfetal birth trauma rectal sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
laborbull Elective
Placenta Factorsbull Placenta previabull Placental abruptionbull Umbilical cord prolapse
Fetal Factorsbull Breech transverse liebull Macrosomiabull Extreme low birth wtbull Fetal distressbull Fetal anomaliesbull Multiple gestation
Cesarean Birth (cont)bull Mortality
morbiditybull 4 x higher than
vaginal birth in US Most risk assoc with emergency c-section
bull Incisionbull Skin vs uterinebull Classical vs low
transverse
bull Maternal Complicationsbull Infectionbull Anesthesia reactionsbull DeepVeinThrombopheb
itisbull Bleedingbull Ureteralbladder injurybull Increase risk for
subsequent pregnancybull Placenta AcretaPrevia
Infertility
Cesarean Birthbull Pre-op CBC w platelets hold clotbull bicitraantacidbull monitor babybull Teaching pre amp post-op anesthesia recovery
breastfeedingbull Psychosocial issues
bull Fearbull Self-imageself-esteem
Post-Op Carebull Assess fundusbleeding vital signs DVTbull Antibiotics bull Pain Duramorph Breakthrough pain
meds Benadryl for itching Zofran for nausea
bull Clear liquids and advance as toleratedbull Assess for GI function Bowel sounds
Passing flatusbull Ambulation Pre-medicate teach splinting
with pillowbull Stool softener
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
multiparity excessive analgesia Afterpains wwwyoutubecomwatchv=EbItF_7KYCcampfeature=related
Fundal Assessment Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina Cervix returns to firm nongravid consistency
by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum Assessment turn pt to side in Simrsquos
position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments Constipation Give stool softeners as
ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis Superficial leg vein disease
ndash Ss tenderness in portion of vein local heat amp redness normal temperature or low-grade fever
ndash Tx local heat elevate limb bed rest analgesia elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation Engorgement day 3 or 4
ndash If breastfeeding Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
Postpartum Complications Postpartum Hemorrhage
ndash CAUSES Uterine atony lacerations retained placental fragments
Risk factorsndash uarr uterine distension multiples polyhydramnios
macrosomia fibroidsndash Trauma rapid or operative birthndash Placental problems previa accreta abruptio
retained placental fragmentsndash Atonic uterus prolonged pitocin magnesium
sulfate or labor uarr maternal age or parity uterine scar chorioamnionitis anemia prior history
ndash Inadequate blood coagulation fetal death or DIC
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
Childbirth at Risk (Ch 26)
Complications of Labor or Delivery
Critical Thinking The client in active labor is requesting pain relief The
physician orders epidural anesthesia for the client Which of the following parameters should the nurse
be prepared to assess immediately after administration of the epidural
bull A) For headache bull B) For urinary retention bull C) The blood pressure bull D) The maternal pulse rate
Precipitous Labor amp Birthbull Labor in lt 3 hoursbull Risk factors
bull Multiparity oxytocin or amniotomy hx of precipitate labor
bull Risks for injurybull Maternal cervical vaginal amp perineal
lacerations with possible hemorrhage pain anxiety
bull Fetal Birth trauma (intracranial bleed brachial palsy) meconium-stained fluid fetal distress
bull Management close monitoring for cervical changes induction
Postterm Pregnancybull gt 42 weeksbull Maternal risks traumahemorrhage due
to larger baby uarroperative deliveryc-section
bull Fetal risks placental changes that darroxygenation to baby and uarrmortality rate oligohydramnios (uarrcord compression during labor) LGA baby (uarrbirth trauma shoulder dystocia) meconium aspiration
bull Management gt 40 wks NST BPP or modified BPP (NST amp AFI) induction
Malpresentationsbull Occiput-posterior (OP)
bull Prolonged labor back labor (sacral nerve compression) arrested dilatation descent perineal tears
bull Usually vaginal but may need C-Section if baby doesnrsquot rotate
bull Management positioning (side-lying knee-chest or hand-knees) sacral pressure during UCrsquos
bull Transverse Liebull Associated with pendulous abdomen uterine
massesfibroids congenital abnormalities of uterus hydramnios
bull Attempt External Cephalic Version if unsuccessful obligatory C-section
Malpresentations (cont)bull Breech presentation
Assessment FHT heard high on the abdomen Leopoldrsquos vaginal exam amp USbull Higher risk of anoxia from prolapsed cord traumatic injury to
the after coming head fracture of spine or arm dysfunctional labor
bull Usually delivered by C-section
External Versionbull External cephalic version (37-38 wks) abdominal
manipulation to change fetal presentationbull Contraindications multiple gestation fetal
breech is engaged in pelvis oligohydramnios nonreactive NST nuchal cord vaginal bleeding IUGR ROM
bull Risks immediate cesarean birthbull Nursing actions NPO 8 hrs NST IV line
terbutaline continuous FHR US used to guide manipulations assess for labor fetal distress O- moms need Rhogam following the procedure
MacrosomiaShoulder Dystociabull Wt gt 4500 gms (9-10 lbs)bull Associated with
bull DM Gestational DM Multiparity Postdates obesitybull Risks
bull Shoulder dystocia difficulty delivering the shoulders after head is delivered (obstetrical emergency)
bull Maternal vaginalcervical tears pp hemorrhage rupturebull Fetal compressed cord fractured clavical asphyxia amp neurologic
damage brachial plexus injury (ErbrsquosPalsy)bull SS Turtle signbull Nursing interventions McRoberts maneuvers suprapubic
pressure PP assess for uterine atonyhemorrhage trauma cerebral or neurologic damage to baby
Video youtubecomwatchv=jV6g427UMxYampfeature=related
McRoberts Maneuvers Video
Multiple Gestationbull Monozygotic (identical) twins can have 1 or 2 placentas
chorions or amnions (uarrrisk if all shared)bull Dizygotic (fraternal) twins 2 of everything
bull Dx faster than usual growth of uterus uarrAFP HCG Ultrasound
bull Risks bull Maternal SAB gestational DM HTNpreeclampsiaHELLP
hydramnios PT labor amp deliverybull Fetal Preterm birth twin-to-twin transfusion
Multiple Gestation (cont)bull Management
bull US to determine what type of twinsbull Prevention of PT laborroutine cervical measurements
(US)bull NST surveillance bull Birth depends on maternal amp fetal complications and
fetal position presentationbull Examination of placentabull Close monitoring PP for hemorrhage (atony)
Abruptio Placentaebull Premature separation of placenta from uterine wallbull SS sharp stabbing pain high in fundus heavy
bleeding (may be occult) hard board-like uterus tense painful uterus signs of shock due to blood loss Port-Wine aminotic fluid if ROM
bull Predisposing fx uarrparity adv maternal age short umbilical cord chronic HTN PIH direct trauma vasoconstriction from cocaine or cigarette use
bull Fetal distress on monitor Can progress to DIC
Abruptio Placentae (cont)bull Management
bull Emergency Immediate c-section if birth not imminent
bull Lg gauge IV bull O2 via mask fetal monitoring
maternal VS lateral positioning labs blood transfusion (have 2 units avail)
bull CBC (HampH) Fibrinogen levels platelet count PTPTT fibrin degradation products ( sx of DIC)
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
for pp hemorrhage
bull Table 26-6 pg 746 differential dx abruptioprevia
Low-lying Marginal
Partial Complete
Placenta Previas
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
Diabetes Pulmonary disease Pregnancy-induced hypertension)
bull Chorioamnionitisbull Suspected fetal problems- Intrauterine Growth
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Inductionbull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessmentbull Bishop Score- rating that determines if the cervix
is ready for induction--Pg 765bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole -Inadequate uterine relaxation between contractions lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveriesbull Forceps
bull Indications unable to push arrested descent need a quick delivery breech
bull Associated with maternalfetal birth trauma rectal sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
laborbull Elective
Placenta Factorsbull Placenta previabull Placental abruptionbull Umbilical cord prolapse
Fetal Factorsbull Breech transverse liebull Macrosomiabull Extreme low birth wtbull Fetal distressbull Fetal anomaliesbull Multiple gestation
Cesarean Birth (cont)bull Mortality
morbiditybull 4 x higher than
vaginal birth in US Most risk assoc with emergency c-section
bull Incisionbull Skin vs uterinebull Classical vs low
transverse
bull Maternal Complicationsbull Infectionbull Anesthesia reactionsbull DeepVeinThrombopheb
itisbull Bleedingbull Ureteralbladder injurybull Increase risk for
subsequent pregnancybull Placenta AcretaPrevia
Infertility
Cesarean Birthbull Pre-op CBC w platelets hold clotbull bicitraantacidbull monitor babybull Teaching pre amp post-op anesthesia recovery
breastfeedingbull Psychosocial issues
bull Fearbull Self-imageself-esteem
Post-Op Carebull Assess fundusbleeding vital signs DVTbull Antibiotics bull Pain Duramorph Breakthrough pain
meds Benadryl for itching Zofran for nausea
bull Clear liquids and advance as toleratedbull Assess for GI function Bowel sounds
Passing flatusbull Ambulation Pre-medicate teach splinting
with pillowbull Stool softener
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
multiparity excessive analgesia Afterpains wwwyoutubecomwatchv=EbItF_7KYCcampfeature=related
Fundal Assessment Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina Cervix returns to firm nongravid consistency
by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum Assessment turn pt to side in Simrsquos
position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments Constipation Give stool softeners as
ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis Superficial leg vein disease
ndash Ss tenderness in portion of vein local heat amp redness normal temperature or low-grade fever
ndash Tx local heat elevate limb bed rest analgesia elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation Engorgement day 3 or 4
ndash If breastfeeding Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
Postpartum Complications Postpartum Hemorrhage
ndash CAUSES Uterine atony lacerations retained placental fragments
Risk factorsndash uarr uterine distension multiples polyhydramnios
macrosomia fibroidsndash Trauma rapid or operative birthndash Placental problems previa accreta abruptio
retained placental fragmentsndash Atonic uterus prolonged pitocin magnesium
sulfate or labor uarr maternal age or parity uterine scar chorioamnionitis anemia prior history
ndash Inadequate blood coagulation fetal death or DIC
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
Critical Thinking The client in active labor is requesting pain relief The
physician orders epidural anesthesia for the client Which of the following parameters should the nurse
be prepared to assess immediately after administration of the epidural
bull A) For headache bull B) For urinary retention bull C) The blood pressure bull D) The maternal pulse rate
Precipitous Labor amp Birthbull Labor in lt 3 hoursbull Risk factors
bull Multiparity oxytocin or amniotomy hx of precipitate labor
bull Risks for injurybull Maternal cervical vaginal amp perineal
lacerations with possible hemorrhage pain anxiety
bull Fetal Birth trauma (intracranial bleed brachial palsy) meconium-stained fluid fetal distress
bull Management close monitoring for cervical changes induction
Postterm Pregnancybull gt 42 weeksbull Maternal risks traumahemorrhage due
to larger baby uarroperative deliveryc-section
bull Fetal risks placental changes that darroxygenation to baby and uarrmortality rate oligohydramnios (uarrcord compression during labor) LGA baby (uarrbirth trauma shoulder dystocia) meconium aspiration
bull Management gt 40 wks NST BPP or modified BPP (NST amp AFI) induction
Malpresentationsbull Occiput-posterior (OP)
bull Prolonged labor back labor (sacral nerve compression) arrested dilatation descent perineal tears
bull Usually vaginal but may need C-Section if baby doesnrsquot rotate
bull Management positioning (side-lying knee-chest or hand-knees) sacral pressure during UCrsquos
bull Transverse Liebull Associated with pendulous abdomen uterine
massesfibroids congenital abnormalities of uterus hydramnios
bull Attempt External Cephalic Version if unsuccessful obligatory C-section
Malpresentations (cont)bull Breech presentation
Assessment FHT heard high on the abdomen Leopoldrsquos vaginal exam amp USbull Higher risk of anoxia from prolapsed cord traumatic injury to
the after coming head fracture of spine or arm dysfunctional labor
bull Usually delivered by C-section
External Versionbull External cephalic version (37-38 wks) abdominal
manipulation to change fetal presentationbull Contraindications multiple gestation fetal
breech is engaged in pelvis oligohydramnios nonreactive NST nuchal cord vaginal bleeding IUGR ROM
bull Risks immediate cesarean birthbull Nursing actions NPO 8 hrs NST IV line
terbutaline continuous FHR US used to guide manipulations assess for labor fetal distress O- moms need Rhogam following the procedure
MacrosomiaShoulder Dystociabull Wt gt 4500 gms (9-10 lbs)bull Associated with
bull DM Gestational DM Multiparity Postdates obesitybull Risks
bull Shoulder dystocia difficulty delivering the shoulders after head is delivered (obstetrical emergency)
bull Maternal vaginalcervical tears pp hemorrhage rupturebull Fetal compressed cord fractured clavical asphyxia amp neurologic
damage brachial plexus injury (ErbrsquosPalsy)bull SS Turtle signbull Nursing interventions McRoberts maneuvers suprapubic
pressure PP assess for uterine atonyhemorrhage trauma cerebral or neurologic damage to baby
Video youtubecomwatchv=jV6g427UMxYampfeature=related
McRoberts Maneuvers Video
Multiple Gestationbull Monozygotic (identical) twins can have 1 or 2 placentas
chorions or amnions (uarrrisk if all shared)bull Dizygotic (fraternal) twins 2 of everything
bull Dx faster than usual growth of uterus uarrAFP HCG Ultrasound
bull Risks bull Maternal SAB gestational DM HTNpreeclampsiaHELLP
hydramnios PT labor amp deliverybull Fetal Preterm birth twin-to-twin transfusion
Multiple Gestation (cont)bull Management
bull US to determine what type of twinsbull Prevention of PT laborroutine cervical measurements
(US)bull NST surveillance bull Birth depends on maternal amp fetal complications and
fetal position presentationbull Examination of placentabull Close monitoring PP for hemorrhage (atony)
Abruptio Placentaebull Premature separation of placenta from uterine wallbull SS sharp stabbing pain high in fundus heavy
bleeding (may be occult) hard board-like uterus tense painful uterus signs of shock due to blood loss Port-Wine aminotic fluid if ROM
bull Predisposing fx uarrparity adv maternal age short umbilical cord chronic HTN PIH direct trauma vasoconstriction from cocaine or cigarette use
bull Fetal distress on monitor Can progress to DIC
Abruptio Placentae (cont)bull Management
bull Emergency Immediate c-section if birth not imminent
bull Lg gauge IV bull O2 via mask fetal monitoring
maternal VS lateral positioning labs blood transfusion (have 2 units avail)
bull CBC (HampH) Fibrinogen levels platelet count PTPTT fibrin degradation products ( sx of DIC)
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
for pp hemorrhage
bull Table 26-6 pg 746 differential dx abruptioprevia
Low-lying Marginal
Partial Complete
Placenta Previas
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
Diabetes Pulmonary disease Pregnancy-induced hypertension)
bull Chorioamnionitisbull Suspected fetal problems- Intrauterine Growth
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Inductionbull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessmentbull Bishop Score- rating that determines if the cervix
is ready for induction--Pg 765bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole -Inadequate uterine relaxation between contractions lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveriesbull Forceps
bull Indications unable to push arrested descent need a quick delivery breech
bull Associated with maternalfetal birth trauma rectal sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
laborbull Elective
Placenta Factorsbull Placenta previabull Placental abruptionbull Umbilical cord prolapse
Fetal Factorsbull Breech transverse liebull Macrosomiabull Extreme low birth wtbull Fetal distressbull Fetal anomaliesbull Multiple gestation
Cesarean Birth (cont)bull Mortality
morbiditybull 4 x higher than
vaginal birth in US Most risk assoc with emergency c-section
bull Incisionbull Skin vs uterinebull Classical vs low
transverse
bull Maternal Complicationsbull Infectionbull Anesthesia reactionsbull DeepVeinThrombopheb
itisbull Bleedingbull Ureteralbladder injurybull Increase risk for
subsequent pregnancybull Placenta AcretaPrevia
Infertility
Cesarean Birthbull Pre-op CBC w platelets hold clotbull bicitraantacidbull monitor babybull Teaching pre amp post-op anesthesia recovery
breastfeedingbull Psychosocial issues
bull Fearbull Self-imageself-esteem
Post-Op Carebull Assess fundusbleeding vital signs DVTbull Antibiotics bull Pain Duramorph Breakthrough pain
meds Benadryl for itching Zofran for nausea
bull Clear liquids and advance as toleratedbull Assess for GI function Bowel sounds
Passing flatusbull Ambulation Pre-medicate teach splinting
with pillowbull Stool softener
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
multiparity excessive analgesia Afterpains wwwyoutubecomwatchv=EbItF_7KYCcampfeature=related
Fundal Assessment Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina Cervix returns to firm nongravid consistency
by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum Assessment turn pt to side in Simrsquos
position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments Constipation Give stool softeners as
ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis Superficial leg vein disease
ndash Ss tenderness in portion of vein local heat amp redness normal temperature or low-grade fever
ndash Tx local heat elevate limb bed rest analgesia elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation Engorgement day 3 or 4
ndash If breastfeeding Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
Postpartum Complications Postpartum Hemorrhage
ndash CAUSES Uterine atony lacerations retained placental fragments
Risk factorsndash uarr uterine distension multiples polyhydramnios
macrosomia fibroidsndash Trauma rapid or operative birthndash Placental problems previa accreta abruptio
retained placental fragmentsndash Atonic uterus prolonged pitocin magnesium
sulfate or labor uarr maternal age or parity uterine scar chorioamnionitis anemia prior history
ndash Inadequate blood coagulation fetal death or DIC
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
Precipitous Labor amp Birthbull Labor in lt 3 hoursbull Risk factors
bull Multiparity oxytocin or amniotomy hx of precipitate labor
bull Risks for injurybull Maternal cervical vaginal amp perineal
lacerations with possible hemorrhage pain anxiety
bull Fetal Birth trauma (intracranial bleed brachial palsy) meconium-stained fluid fetal distress
bull Management close monitoring for cervical changes induction
Postterm Pregnancybull gt 42 weeksbull Maternal risks traumahemorrhage due
to larger baby uarroperative deliveryc-section
bull Fetal risks placental changes that darroxygenation to baby and uarrmortality rate oligohydramnios (uarrcord compression during labor) LGA baby (uarrbirth trauma shoulder dystocia) meconium aspiration
bull Management gt 40 wks NST BPP or modified BPP (NST amp AFI) induction
Malpresentationsbull Occiput-posterior (OP)
bull Prolonged labor back labor (sacral nerve compression) arrested dilatation descent perineal tears
bull Usually vaginal but may need C-Section if baby doesnrsquot rotate
bull Management positioning (side-lying knee-chest or hand-knees) sacral pressure during UCrsquos
bull Transverse Liebull Associated with pendulous abdomen uterine
massesfibroids congenital abnormalities of uterus hydramnios
bull Attempt External Cephalic Version if unsuccessful obligatory C-section
Malpresentations (cont)bull Breech presentation
Assessment FHT heard high on the abdomen Leopoldrsquos vaginal exam amp USbull Higher risk of anoxia from prolapsed cord traumatic injury to
the after coming head fracture of spine or arm dysfunctional labor
bull Usually delivered by C-section
External Versionbull External cephalic version (37-38 wks) abdominal
manipulation to change fetal presentationbull Contraindications multiple gestation fetal
breech is engaged in pelvis oligohydramnios nonreactive NST nuchal cord vaginal bleeding IUGR ROM
bull Risks immediate cesarean birthbull Nursing actions NPO 8 hrs NST IV line
terbutaline continuous FHR US used to guide manipulations assess for labor fetal distress O- moms need Rhogam following the procedure
MacrosomiaShoulder Dystociabull Wt gt 4500 gms (9-10 lbs)bull Associated with
bull DM Gestational DM Multiparity Postdates obesitybull Risks
bull Shoulder dystocia difficulty delivering the shoulders after head is delivered (obstetrical emergency)
bull Maternal vaginalcervical tears pp hemorrhage rupturebull Fetal compressed cord fractured clavical asphyxia amp neurologic
damage brachial plexus injury (ErbrsquosPalsy)bull SS Turtle signbull Nursing interventions McRoberts maneuvers suprapubic
pressure PP assess for uterine atonyhemorrhage trauma cerebral or neurologic damage to baby
Video youtubecomwatchv=jV6g427UMxYampfeature=related
McRoberts Maneuvers Video
Multiple Gestationbull Monozygotic (identical) twins can have 1 or 2 placentas
chorions or amnions (uarrrisk if all shared)bull Dizygotic (fraternal) twins 2 of everything
bull Dx faster than usual growth of uterus uarrAFP HCG Ultrasound
bull Risks bull Maternal SAB gestational DM HTNpreeclampsiaHELLP
hydramnios PT labor amp deliverybull Fetal Preterm birth twin-to-twin transfusion
Multiple Gestation (cont)bull Management
bull US to determine what type of twinsbull Prevention of PT laborroutine cervical measurements
(US)bull NST surveillance bull Birth depends on maternal amp fetal complications and
fetal position presentationbull Examination of placentabull Close monitoring PP for hemorrhage (atony)
Abruptio Placentaebull Premature separation of placenta from uterine wallbull SS sharp stabbing pain high in fundus heavy
bleeding (may be occult) hard board-like uterus tense painful uterus signs of shock due to blood loss Port-Wine aminotic fluid if ROM
bull Predisposing fx uarrparity adv maternal age short umbilical cord chronic HTN PIH direct trauma vasoconstriction from cocaine or cigarette use
bull Fetal distress on monitor Can progress to DIC
Abruptio Placentae (cont)bull Management
bull Emergency Immediate c-section if birth not imminent
bull Lg gauge IV bull O2 via mask fetal monitoring
maternal VS lateral positioning labs blood transfusion (have 2 units avail)
bull CBC (HampH) Fibrinogen levels platelet count PTPTT fibrin degradation products ( sx of DIC)
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
for pp hemorrhage
bull Table 26-6 pg 746 differential dx abruptioprevia
Low-lying Marginal
Partial Complete
Placenta Previas
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
Diabetes Pulmonary disease Pregnancy-induced hypertension)
bull Chorioamnionitisbull Suspected fetal problems- Intrauterine Growth
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Inductionbull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessmentbull Bishop Score- rating that determines if the cervix
is ready for induction--Pg 765bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole -Inadequate uterine relaxation between contractions lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveriesbull Forceps
bull Indications unable to push arrested descent need a quick delivery breech
bull Associated with maternalfetal birth trauma rectal sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
laborbull Elective
Placenta Factorsbull Placenta previabull Placental abruptionbull Umbilical cord prolapse
Fetal Factorsbull Breech transverse liebull Macrosomiabull Extreme low birth wtbull Fetal distressbull Fetal anomaliesbull Multiple gestation
Cesarean Birth (cont)bull Mortality
morbiditybull 4 x higher than
vaginal birth in US Most risk assoc with emergency c-section
bull Incisionbull Skin vs uterinebull Classical vs low
transverse
bull Maternal Complicationsbull Infectionbull Anesthesia reactionsbull DeepVeinThrombopheb
itisbull Bleedingbull Ureteralbladder injurybull Increase risk for
subsequent pregnancybull Placenta AcretaPrevia
Infertility
Cesarean Birthbull Pre-op CBC w platelets hold clotbull bicitraantacidbull monitor babybull Teaching pre amp post-op anesthesia recovery
breastfeedingbull Psychosocial issues
bull Fearbull Self-imageself-esteem
Post-Op Carebull Assess fundusbleeding vital signs DVTbull Antibiotics bull Pain Duramorph Breakthrough pain
meds Benadryl for itching Zofran for nausea
bull Clear liquids and advance as toleratedbull Assess for GI function Bowel sounds
Passing flatusbull Ambulation Pre-medicate teach splinting
with pillowbull Stool softener
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
multiparity excessive analgesia Afterpains wwwyoutubecomwatchv=EbItF_7KYCcampfeature=related
Fundal Assessment Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina Cervix returns to firm nongravid consistency
by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum Assessment turn pt to side in Simrsquos
position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments Constipation Give stool softeners as
ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis Superficial leg vein disease
ndash Ss tenderness in portion of vein local heat amp redness normal temperature or low-grade fever
ndash Tx local heat elevate limb bed rest analgesia elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation Engorgement day 3 or 4
ndash If breastfeeding Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
Postpartum Complications Postpartum Hemorrhage
ndash CAUSES Uterine atony lacerations retained placental fragments
Risk factorsndash uarr uterine distension multiples polyhydramnios
macrosomia fibroidsndash Trauma rapid or operative birthndash Placental problems previa accreta abruptio
retained placental fragmentsndash Atonic uterus prolonged pitocin magnesium
sulfate or labor uarr maternal age or parity uterine scar chorioamnionitis anemia prior history
ndash Inadequate blood coagulation fetal death or DIC
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
Postterm Pregnancybull gt 42 weeksbull Maternal risks traumahemorrhage due
to larger baby uarroperative deliveryc-section
bull Fetal risks placental changes that darroxygenation to baby and uarrmortality rate oligohydramnios (uarrcord compression during labor) LGA baby (uarrbirth trauma shoulder dystocia) meconium aspiration
bull Management gt 40 wks NST BPP or modified BPP (NST amp AFI) induction
Malpresentationsbull Occiput-posterior (OP)
bull Prolonged labor back labor (sacral nerve compression) arrested dilatation descent perineal tears
bull Usually vaginal but may need C-Section if baby doesnrsquot rotate
bull Management positioning (side-lying knee-chest or hand-knees) sacral pressure during UCrsquos
bull Transverse Liebull Associated with pendulous abdomen uterine
massesfibroids congenital abnormalities of uterus hydramnios
bull Attempt External Cephalic Version if unsuccessful obligatory C-section
Malpresentations (cont)bull Breech presentation
Assessment FHT heard high on the abdomen Leopoldrsquos vaginal exam amp USbull Higher risk of anoxia from prolapsed cord traumatic injury to
the after coming head fracture of spine or arm dysfunctional labor
bull Usually delivered by C-section
External Versionbull External cephalic version (37-38 wks) abdominal
manipulation to change fetal presentationbull Contraindications multiple gestation fetal
breech is engaged in pelvis oligohydramnios nonreactive NST nuchal cord vaginal bleeding IUGR ROM
bull Risks immediate cesarean birthbull Nursing actions NPO 8 hrs NST IV line
terbutaline continuous FHR US used to guide manipulations assess for labor fetal distress O- moms need Rhogam following the procedure
MacrosomiaShoulder Dystociabull Wt gt 4500 gms (9-10 lbs)bull Associated with
bull DM Gestational DM Multiparity Postdates obesitybull Risks
bull Shoulder dystocia difficulty delivering the shoulders after head is delivered (obstetrical emergency)
bull Maternal vaginalcervical tears pp hemorrhage rupturebull Fetal compressed cord fractured clavical asphyxia amp neurologic
damage brachial plexus injury (ErbrsquosPalsy)bull SS Turtle signbull Nursing interventions McRoberts maneuvers suprapubic
pressure PP assess for uterine atonyhemorrhage trauma cerebral or neurologic damage to baby
Video youtubecomwatchv=jV6g427UMxYampfeature=related
McRoberts Maneuvers Video
Multiple Gestationbull Monozygotic (identical) twins can have 1 or 2 placentas
chorions or amnions (uarrrisk if all shared)bull Dizygotic (fraternal) twins 2 of everything
bull Dx faster than usual growth of uterus uarrAFP HCG Ultrasound
bull Risks bull Maternal SAB gestational DM HTNpreeclampsiaHELLP
hydramnios PT labor amp deliverybull Fetal Preterm birth twin-to-twin transfusion
Multiple Gestation (cont)bull Management
bull US to determine what type of twinsbull Prevention of PT laborroutine cervical measurements
(US)bull NST surveillance bull Birth depends on maternal amp fetal complications and
fetal position presentationbull Examination of placentabull Close monitoring PP for hemorrhage (atony)
Abruptio Placentaebull Premature separation of placenta from uterine wallbull SS sharp stabbing pain high in fundus heavy
bleeding (may be occult) hard board-like uterus tense painful uterus signs of shock due to blood loss Port-Wine aminotic fluid if ROM
bull Predisposing fx uarrparity adv maternal age short umbilical cord chronic HTN PIH direct trauma vasoconstriction from cocaine or cigarette use
bull Fetal distress on monitor Can progress to DIC
Abruptio Placentae (cont)bull Management
bull Emergency Immediate c-section if birth not imminent
bull Lg gauge IV bull O2 via mask fetal monitoring
maternal VS lateral positioning labs blood transfusion (have 2 units avail)
bull CBC (HampH) Fibrinogen levels platelet count PTPTT fibrin degradation products ( sx of DIC)
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
for pp hemorrhage
bull Table 26-6 pg 746 differential dx abruptioprevia
Low-lying Marginal
Partial Complete
Placenta Previas
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
Diabetes Pulmonary disease Pregnancy-induced hypertension)
bull Chorioamnionitisbull Suspected fetal problems- Intrauterine Growth
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Inductionbull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessmentbull Bishop Score- rating that determines if the cervix
is ready for induction--Pg 765bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole -Inadequate uterine relaxation between contractions lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveriesbull Forceps
bull Indications unable to push arrested descent need a quick delivery breech
bull Associated with maternalfetal birth trauma rectal sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
laborbull Elective
Placenta Factorsbull Placenta previabull Placental abruptionbull Umbilical cord prolapse
Fetal Factorsbull Breech transverse liebull Macrosomiabull Extreme low birth wtbull Fetal distressbull Fetal anomaliesbull Multiple gestation
Cesarean Birth (cont)bull Mortality
morbiditybull 4 x higher than
vaginal birth in US Most risk assoc with emergency c-section
bull Incisionbull Skin vs uterinebull Classical vs low
transverse
bull Maternal Complicationsbull Infectionbull Anesthesia reactionsbull DeepVeinThrombopheb
itisbull Bleedingbull Ureteralbladder injurybull Increase risk for
subsequent pregnancybull Placenta AcretaPrevia
Infertility
Cesarean Birthbull Pre-op CBC w platelets hold clotbull bicitraantacidbull monitor babybull Teaching pre amp post-op anesthesia recovery
breastfeedingbull Psychosocial issues
bull Fearbull Self-imageself-esteem
Post-Op Carebull Assess fundusbleeding vital signs DVTbull Antibiotics bull Pain Duramorph Breakthrough pain
meds Benadryl for itching Zofran for nausea
bull Clear liquids and advance as toleratedbull Assess for GI function Bowel sounds
Passing flatusbull Ambulation Pre-medicate teach splinting
with pillowbull Stool softener
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
multiparity excessive analgesia Afterpains wwwyoutubecomwatchv=EbItF_7KYCcampfeature=related
Fundal Assessment Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina Cervix returns to firm nongravid consistency
by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum Assessment turn pt to side in Simrsquos
position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments Constipation Give stool softeners as
ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis Superficial leg vein disease
ndash Ss tenderness in portion of vein local heat amp redness normal temperature or low-grade fever
ndash Tx local heat elevate limb bed rest analgesia elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation Engorgement day 3 or 4
ndash If breastfeeding Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
Postpartum Complications Postpartum Hemorrhage
ndash CAUSES Uterine atony lacerations retained placental fragments
Risk factorsndash uarr uterine distension multiples polyhydramnios
macrosomia fibroidsndash Trauma rapid or operative birthndash Placental problems previa accreta abruptio
retained placental fragmentsndash Atonic uterus prolonged pitocin magnesium
sulfate or labor uarr maternal age or parity uterine scar chorioamnionitis anemia prior history
ndash Inadequate blood coagulation fetal death or DIC
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
Malpresentationsbull Occiput-posterior (OP)
bull Prolonged labor back labor (sacral nerve compression) arrested dilatation descent perineal tears
bull Usually vaginal but may need C-Section if baby doesnrsquot rotate
bull Management positioning (side-lying knee-chest or hand-knees) sacral pressure during UCrsquos
bull Transverse Liebull Associated with pendulous abdomen uterine
massesfibroids congenital abnormalities of uterus hydramnios
bull Attempt External Cephalic Version if unsuccessful obligatory C-section
Malpresentations (cont)bull Breech presentation
Assessment FHT heard high on the abdomen Leopoldrsquos vaginal exam amp USbull Higher risk of anoxia from prolapsed cord traumatic injury to
the after coming head fracture of spine or arm dysfunctional labor
bull Usually delivered by C-section
External Versionbull External cephalic version (37-38 wks) abdominal
manipulation to change fetal presentationbull Contraindications multiple gestation fetal
breech is engaged in pelvis oligohydramnios nonreactive NST nuchal cord vaginal bleeding IUGR ROM
bull Risks immediate cesarean birthbull Nursing actions NPO 8 hrs NST IV line
terbutaline continuous FHR US used to guide manipulations assess for labor fetal distress O- moms need Rhogam following the procedure
MacrosomiaShoulder Dystociabull Wt gt 4500 gms (9-10 lbs)bull Associated with
bull DM Gestational DM Multiparity Postdates obesitybull Risks
bull Shoulder dystocia difficulty delivering the shoulders after head is delivered (obstetrical emergency)
bull Maternal vaginalcervical tears pp hemorrhage rupturebull Fetal compressed cord fractured clavical asphyxia amp neurologic
damage brachial plexus injury (ErbrsquosPalsy)bull SS Turtle signbull Nursing interventions McRoberts maneuvers suprapubic
pressure PP assess for uterine atonyhemorrhage trauma cerebral or neurologic damage to baby
Video youtubecomwatchv=jV6g427UMxYampfeature=related
McRoberts Maneuvers Video
Multiple Gestationbull Monozygotic (identical) twins can have 1 or 2 placentas
chorions or amnions (uarrrisk if all shared)bull Dizygotic (fraternal) twins 2 of everything
bull Dx faster than usual growth of uterus uarrAFP HCG Ultrasound
bull Risks bull Maternal SAB gestational DM HTNpreeclampsiaHELLP
hydramnios PT labor amp deliverybull Fetal Preterm birth twin-to-twin transfusion
Multiple Gestation (cont)bull Management
bull US to determine what type of twinsbull Prevention of PT laborroutine cervical measurements
(US)bull NST surveillance bull Birth depends on maternal amp fetal complications and
fetal position presentationbull Examination of placentabull Close monitoring PP for hemorrhage (atony)
Abruptio Placentaebull Premature separation of placenta from uterine wallbull SS sharp stabbing pain high in fundus heavy
bleeding (may be occult) hard board-like uterus tense painful uterus signs of shock due to blood loss Port-Wine aminotic fluid if ROM
bull Predisposing fx uarrparity adv maternal age short umbilical cord chronic HTN PIH direct trauma vasoconstriction from cocaine or cigarette use
bull Fetal distress on monitor Can progress to DIC
Abruptio Placentae (cont)bull Management
bull Emergency Immediate c-section if birth not imminent
bull Lg gauge IV bull O2 via mask fetal monitoring
maternal VS lateral positioning labs blood transfusion (have 2 units avail)
bull CBC (HampH) Fibrinogen levels platelet count PTPTT fibrin degradation products ( sx of DIC)
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
for pp hemorrhage
bull Table 26-6 pg 746 differential dx abruptioprevia
Low-lying Marginal
Partial Complete
Placenta Previas
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
Diabetes Pulmonary disease Pregnancy-induced hypertension)
bull Chorioamnionitisbull Suspected fetal problems- Intrauterine Growth
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Inductionbull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessmentbull Bishop Score- rating that determines if the cervix
is ready for induction--Pg 765bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole -Inadequate uterine relaxation between contractions lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveriesbull Forceps
bull Indications unable to push arrested descent need a quick delivery breech
bull Associated with maternalfetal birth trauma rectal sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
laborbull Elective
Placenta Factorsbull Placenta previabull Placental abruptionbull Umbilical cord prolapse
Fetal Factorsbull Breech transverse liebull Macrosomiabull Extreme low birth wtbull Fetal distressbull Fetal anomaliesbull Multiple gestation
Cesarean Birth (cont)bull Mortality
morbiditybull 4 x higher than
vaginal birth in US Most risk assoc with emergency c-section
bull Incisionbull Skin vs uterinebull Classical vs low
transverse
bull Maternal Complicationsbull Infectionbull Anesthesia reactionsbull DeepVeinThrombopheb
itisbull Bleedingbull Ureteralbladder injurybull Increase risk for
subsequent pregnancybull Placenta AcretaPrevia
Infertility
Cesarean Birthbull Pre-op CBC w platelets hold clotbull bicitraantacidbull monitor babybull Teaching pre amp post-op anesthesia recovery
breastfeedingbull Psychosocial issues
bull Fearbull Self-imageself-esteem
Post-Op Carebull Assess fundusbleeding vital signs DVTbull Antibiotics bull Pain Duramorph Breakthrough pain
meds Benadryl for itching Zofran for nausea
bull Clear liquids and advance as toleratedbull Assess for GI function Bowel sounds
Passing flatusbull Ambulation Pre-medicate teach splinting
with pillowbull Stool softener
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
multiparity excessive analgesia Afterpains wwwyoutubecomwatchv=EbItF_7KYCcampfeature=related
Fundal Assessment Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina Cervix returns to firm nongravid consistency
by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum Assessment turn pt to side in Simrsquos
position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments Constipation Give stool softeners as
ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis Superficial leg vein disease
ndash Ss tenderness in portion of vein local heat amp redness normal temperature or low-grade fever
ndash Tx local heat elevate limb bed rest analgesia elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation Engorgement day 3 or 4
ndash If breastfeeding Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
Postpartum Complications Postpartum Hemorrhage
ndash CAUSES Uterine atony lacerations retained placental fragments
Risk factorsndash uarr uterine distension multiples polyhydramnios
macrosomia fibroidsndash Trauma rapid or operative birthndash Placental problems previa accreta abruptio
retained placental fragmentsndash Atonic uterus prolonged pitocin magnesium
sulfate or labor uarr maternal age or parity uterine scar chorioamnionitis anemia prior history
ndash Inadequate blood coagulation fetal death or DIC
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
Malpresentations (cont)bull Breech presentation
Assessment FHT heard high on the abdomen Leopoldrsquos vaginal exam amp USbull Higher risk of anoxia from prolapsed cord traumatic injury to
the after coming head fracture of spine or arm dysfunctional labor
bull Usually delivered by C-section
External Versionbull External cephalic version (37-38 wks) abdominal
manipulation to change fetal presentationbull Contraindications multiple gestation fetal
breech is engaged in pelvis oligohydramnios nonreactive NST nuchal cord vaginal bleeding IUGR ROM
bull Risks immediate cesarean birthbull Nursing actions NPO 8 hrs NST IV line
terbutaline continuous FHR US used to guide manipulations assess for labor fetal distress O- moms need Rhogam following the procedure
MacrosomiaShoulder Dystociabull Wt gt 4500 gms (9-10 lbs)bull Associated with
bull DM Gestational DM Multiparity Postdates obesitybull Risks
bull Shoulder dystocia difficulty delivering the shoulders after head is delivered (obstetrical emergency)
bull Maternal vaginalcervical tears pp hemorrhage rupturebull Fetal compressed cord fractured clavical asphyxia amp neurologic
damage brachial plexus injury (ErbrsquosPalsy)bull SS Turtle signbull Nursing interventions McRoberts maneuvers suprapubic
pressure PP assess for uterine atonyhemorrhage trauma cerebral or neurologic damage to baby
Video youtubecomwatchv=jV6g427UMxYampfeature=related
McRoberts Maneuvers Video
Multiple Gestationbull Monozygotic (identical) twins can have 1 or 2 placentas
chorions or amnions (uarrrisk if all shared)bull Dizygotic (fraternal) twins 2 of everything
bull Dx faster than usual growth of uterus uarrAFP HCG Ultrasound
bull Risks bull Maternal SAB gestational DM HTNpreeclampsiaHELLP
hydramnios PT labor amp deliverybull Fetal Preterm birth twin-to-twin transfusion
Multiple Gestation (cont)bull Management
bull US to determine what type of twinsbull Prevention of PT laborroutine cervical measurements
(US)bull NST surveillance bull Birth depends on maternal amp fetal complications and
fetal position presentationbull Examination of placentabull Close monitoring PP for hemorrhage (atony)
Abruptio Placentaebull Premature separation of placenta from uterine wallbull SS sharp stabbing pain high in fundus heavy
bleeding (may be occult) hard board-like uterus tense painful uterus signs of shock due to blood loss Port-Wine aminotic fluid if ROM
bull Predisposing fx uarrparity adv maternal age short umbilical cord chronic HTN PIH direct trauma vasoconstriction from cocaine or cigarette use
bull Fetal distress on monitor Can progress to DIC
Abruptio Placentae (cont)bull Management
bull Emergency Immediate c-section if birth not imminent
bull Lg gauge IV bull O2 via mask fetal monitoring
maternal VS lateral positioning labs blood transfusion (have 2 units avail)
bull CBC (HampH) Fibrinogen levels platelet count PTPTT fibrin degradation products ( sx of DIC)
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
for pp hemorrhage
bull Table 26-6 pg 746 differential dx abruptioprevia
Low-lying Marginal
Partial Complete
Placenta Previas
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
Diabetes Pulmonary disease Pregnancy-induced hypertension)
bull Chorioamnionitisbull Suspected fetal problems- Intrauterine Growth
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Inductionbull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessmentbull Bishop Score- rating that determines if the cervix
is ready for induction--Pg 765bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole -Inadequate uterine relaxation between contractions lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveriesbull Forceps
bull Indications unable to push arrested descent need a quick delivery breech
bull Associated with maternalfetal birth trauma rectal sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
laborbull Elective
Placenta Factorsbull Placenta previabull Placental abruptionbull Umbilical cord prolapse
Fetal Factorsbull Breech transverse liebull Macrosomiabull Extreme low birth wtbull Fetal distressbull Fetal anomaliesbull Multiple gestation
Cesarean Birth (cont)bull Mortality
morbiditybull 4 x higher than
vaginal birth in US Most risk assoc with emergency c-section
bull Incisionbull Skin vs uterinebull Classical vs low
transverse
bull Maternal Complicationsbull Infectionbull Anesthesia reactionsbull DeepVeinThrombopheb
itisbull Bleedingbull Ureteralbladder injurybull Increase risk for
subsequent pregnancybull Placenta AcretaPrevia
Infertility
Cesarean Birthbull Pre-op CBC w platelets hold clotbull bicitraantacidbull monitor babybull Teaching pre amp post-op anesthesia recovery
breastfeedingbull Psychosocial issues
bull Fearbull Self-imageself-esteem
Post-Op Carebull Assess fundusbleeding vital signs DVTbull Antibiotics bull Pain Duramorph Breakthrough pain
meds Benadryl for itching Zofran for nausea
bull Clear liquids and advance as toleratedbull Assess for GI function Bowel sounds
Passing flatusbull Ambulation Pre-medicate teach splinting
with pillowbull Stool softener
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
multiparity excessive analgesia Afterpains wwwyoutubecomwatchv=EbItF_7KYCcampfeature=related
Fundal Assessment Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina Cervix returns to firm nongravid consistency
by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum Assessment turn pt to side in Simrsquos
position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments Constipation Give stool softeners as
ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis Superficial leg vein disease
ndash Ss tenderness in portion of vein local heat amp redness normal temperature or low-grade fever
ndash Tx local heat elevate limb bed rest analgesia elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation Engorgement day 3 or 4
ndash If breastfeeding Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
Postpartum Complications Postpartum Hemorrhage
ndash CAUSES Uterine atony lacerations retained placental fragments
Risk factorsndash uarr uterine distension multiples polyhydramnios
macrosomia fibroidsndash Trauma rapid or operative birthndash Placental problems previa accreta abruptio
retained placental fragmentsndash Atonic uterus prolonged pitocin magnesium
sulfate or labor uarr maternal age or parity uterine scar chorioamnionitis anemia prior history
ndash Inadequate blood coagulation fetal death or DIC
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
External Versionbull External cephalic version (37-38 wks) abdominal
manipulation to change fetal presentationbull Contraindications multiple gestation fetal
breech is engaged in pelvis oligohydramnios nonreactive NST nuchal cord vaginal bleeding IUGR ROM
bull Risks immediate cesarean birthbull Nursing actions NPO 8 hrs NST IV line
terbutaline continuous FHR US used to guide manipulations assess for labor fetal distress O- moms need Rhogam following the procedure
MacrosomiaShoulder Dystociabull Wt gt 4500 gms (9-10 lbs)bull Associated with
bull DM Gestational DM Multiparity Postdates obesitybull Risks
bull Shoulder dystocia difficulty delivering the shoulders after head is delivered (obstetrical emergency)
bull Maternal vaginalcervical tears pp hemorrhage rupturebull Fetal compressed cord fractured clavical asphyxia amp neurologic
damage brachial plexus injury (ErbrsquosPalsy)bull SS Turtle signbull Nursing interventions McRoberts maneuvers suprapubic
pressure PP assess for uterine atonyhemorrhage trauma cerebral or neurologic damage to baby
Video youtubecomwatchv=jV6g427UMxYampfeature=related
McRoberts Maneuvers Video
Multiple Gestationbull Monozygotic (identical) twins can have 1 or 2 placentas
chorions or amnions (uarrrisk if all shared)bull Dizygotic (fraternal) twins 2 of everything
bull Dx faster than usual growth of uterus uarrAFP HCG Ultrasound
bull Risks bull Maternal SAB gestational DM HTNpreeclampsiaHELLP
hydramnios PT labor amp deliverybull Fetal Preterm birth twin-to-twin transfusion
Multiple Gestation (cont)bull Management
bull US to determine what type of twinsbull Prevention of PT laborroutine cervical measurements
(US)bull NST surveillance bull Birth depends on maternal amp fetal complications and
fetal position presentationbull Examination of placentabull Close monitoring PP for hemorrhage (atony)
Abruptio Placentaebull Premature separation of placenta from uterine wallbull SS sharp stabbing pain high in fundus heavy
bleeding (may be occult) hard board-like uterus tense painful uterus signs of shock due to blood loss Port-Wine aminotic fluid if ROM
bull Predisposing fx uarrparity adv maternal age short umbilical cord chronic HTN PIH direct trauma vasoconstriction from cocaine or cigarette use
bull Fetal distress on monitor Can progress to DIC
Abruptio Placentae (cont)bull Management
bull Emergency Immediate c-section if birth not imminent
bull Lg gauge IV bull O2 via mask fetal monitoring
maternal VS lateral positioning labs blood transfusion (have 2 units avail)
bull CBC (HampH) Fibrinogen levels platelet count PTPTT fibrin degradation products ( sx of DIC)
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
for pp hemorrhage
bull Table 26-6 pg 746 differential dx abruptioprevia
Low-lying Marginal
Partial Complete
Placenta Previas
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
Diabetes Pulmonary disease Pregnancy-induced hypertension)
bull Chorioamnionitisbull Suspected fetal problems- Intrauterine Growth
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Inductionbull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessmentbull Bishop Score- rating that determines if the cervix
is ready for induction--Pg 765bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole -Inadequate uterine relaxation between contractions lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveriesbull Forceps
bull Indications unable to push arrested descent need a quick delivery breech
bull Associated with maternalfetal birth trauma rectal sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
laborbull Elective
Placenta Factorsbull Placenta previabull Placental abruptionbull Umbilical cord prolapse
Fetal Factorsbull Breech transverse liebull Macrosomiabull Extreme low birth wtbull Fetal distressbull Fetal anomaliesbull Multiple gestation
Cesarean Birth (cont)bull Mortality
morbiditybull 4 x higher than
vaginal birth in US Most risk assoc with emergency c-section
bull Incisionbull Skin vs uterinebull Classical vs low
transverse
bull Maternal Complicationsbull Infectionbull Anesthesia reactionsbull DeepVeinThrombopheb
itisbull Bleedingbull Ureteralbladder injurybull Increase risk for
subsequent pregnancybull Placenta AcretaPrevia
Infertility
Cesarean Birthbull Pre-op CBC w platelets hold clotbull bicitraantacidbull monitor babybull Teaching pre amp post-op anesthesia recovery
breastfeedingbull Psychosocial issues
bull Fearbull Self-imageself-esteem
Post-Op Carebull Assess fundusbleeding vital signs DVTbull Antibiotics bull Pain Duramorph Breakthrough pain
meds Benadryl for itching Zofran for nausea
bull Clear liquids and advance as toleratedbull Assess for GI function Bowel sounds
Passing flatusbull Ambulation Pre-medicate teach splinting
with pillowbull Stool softener
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
multiparity excessive analgesia Afterpains wwwyoutubecomwatchv=EbItF_7KYCcampfeature=related
Fundal Assessment Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina Cervix returns to firm nongravid consistency
by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum Assessment turn pt to side in Simrsquos
position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments Constipation Give stool softeners as
ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis Superficial leg vein disease
ndash Ss tenderness in portion of vein local heat amp redness normal temperature or low-grade fever
ndash Tx local heat elevate limb bed rest analgesia elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation Engorgement day 3 or 4
ndash If breastfeeding Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
Postpartum Complications Postpartum Hemorrhage
ndash CAUSES Uterine atony lacerations retained placental fragments
Risk factorsndash uarr uterine distension multiples polyhydramnios
macrosomia fibroidsndash Trauma rapid or operative birthndash Placental problems previa accreta abruptio
retained placental fragmentsndash Atonic uterus prolonged pitocin magnesium
sulfate or labor uarr maternal age or parity uterine scar chorioamnionitis anemia prior history
ndash Inadequate blood coagulation fetal death or DIC
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
MacrosomiaShoulder Dystociabull Wt gt 4500 gms (9-10 lbs)bull Associated with
bull DM Gestational DM Multiparity Postdates obesitybull Risks
bull Shoulder dystocia difficulty delivering the shoulders after head is delivered (obstetrical emergency)
bull Maternal vaginalcervical tears pp hemorrhage rupturebull Fetal compressed cord fractured clavical asphyxia amp neurologic
damage brachial plexus injury (ErbrsquosPalsy)bull SS Turtle signbull Nursing interventions McRoberts maneuvers suprapubic
pressure PP assess for uterine atonyhemorrhage trauma cerebral or neurologic damage to baby
Video youtubecomwatchv=jV6g427UMxYampfeature=related
McRoberts Maneuvers Video
Multiple Gestationbull Monozygotic (identical) twins can have 1 or 2 placentas
chorions or amnions (uarrrisk if all shared)bull Dizygotic (fraternal) twins 2 of everything
bull Dx faster than usual growth of uterus uarrAFP HCG Ultrasound
bull Risks bull Maternal SAB gestational DM HTNpreeclampsiaHELLP
hydramnios PT labor amp deliverybull Fetal Preterm birth twin-to-twin transfusion
Multiple Gestation (cont)bull Management
bull US to determine what type of twinsbull Prevention of PT laborroutine cervical measurements
(US)bull NST surveillance bull Birth depends on maternal amp fetal complications and
fetal position presentationbull Examination of placentabull Close monitoring PP for hemorrhage (atony)
Abruptio Placentaebull Premature separation of placenta from uterine wallbull SS sharp stabbing pain high in fundus heavy
bleeding (may be occult) hard board-like uterus tense painful uterus signs of shock due to blood loss Port-Wine aminotic fluid if ROM
bull Predisposing fx uarrparity adv maternal age short umbilical cord chronic HTN PIH direct trauma vasoconstriction from cocaine or cigarette use
bull Fetal distress on monitor Can progress to DIC
Abruptio Placentae (cont)bull Management
bull Emergency Immediate c-section if birth not imminent
bull Lg gauge IV bull O2 via mask fetal monitoring
maternal VS lateral positioning labs blood transfusion (have 2 units avail)
bull CBC (HampH) Fibrinogen levels platelet count PTPTT fibrin degradation products ( sx of DIC)
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
for pp hemorrhage
bull Table 26-6 pg 746 differential dx abruptioprevia
Low-lying Marginal
Partial Complete
Placenta Previas
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
Diabetes Pulmonary disease Pregnancy-induced hypertension)
bull Chorioamnionitisbull Suspected fetal problems- Intrauterine Growth
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Inductionbull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessmentbull Bishop Score- rating that determines if the cervix
is ready for induction--Pg 765bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole -Inadequate uterine relaxation between contractions lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveriesbull Forceps
bull Indications unable to push arrested descent need a quick delivery breech
bull Associated with maternalfetal birth trauma rectal sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
laborbull Elective
Placenta Factorsbull Placenta previabull Placental abruptionbull Umbilical cord prolapse
Fetal Factorsbull Breech transverse liebull Macrosomiabull Extreme low birth wtbull Fetal distressbull Fetal anomaliesbull Multiple gestation
Cesarean Birth (cont)bull Mortality
morbiditybull 4 x higher than
vaginal birth in US Most risk assoc with emergency c-section
bull Incisionbull Skin vs uterinebull Classical vs low
transverse
bull Maternal Complicationsbull Infectionbull Anesthesia reactionsbull DeepVeinThrombopheb
itisbull Bleedingbull Ureteralbladder injurybull Increase risk for
subsequent pregnancybull Placenta AcretaPrevia
Infertility
Cesarean Birthbull Pre-op CBC w platelets hold clotbull bicitraantacidbull monitor babybull Teaching pre amp post-op anesthesia recovery
breastfeedingbull Psychosocial issues
bull Fearbull Self-imageself-esteem
Post-Op Carebull Assess fundusbleeding vital signs DVTbull Antibiotics bull Pain Duramorph Breakthrough pain
meds Benadryl for itching Zofran for nausea
bull Clear liquids and advance as toleratedbull Assess for GI function Bowel sounds
Passing flatusbull Ambulation Pre-medicate teach splinting
with pillowbull Stool softener
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
multiparity excessive analgesia Afterpains wwwyoutubecomwatchv=EbItF_7KYCcampfeature=related
Fundal Assessment Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina Cervix returns to firm nongravid consistency
by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum Assessment turn pt to side in Simrsquos
position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments Constipation Give stool softeners as
ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis Superficial leg vein disease
ndash Ss tenderness in portion of vein local heat amp redness normal temperature or low-grade fever
ndash Tx local heat elevate limb bed rest analgesia elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation Engorgement day 3 or 4
ndash If breastfeeding Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
Postpartum Complications Postpartum Hemorrhage
ndash CAUSES Uterine atony lacerations retained placental fragments
Risk factorsndash uarr uterine distension multiples polyhydramnios
macrosomia fibroidsndash Trauma rapid or operative birthndash Placental problems previa accreta abruptio
retained placental fragmentsndash Atonic uterus prolonged pitocin magnesium
sulfate or labor uarr maternal age or parity uterine scar chorioamnionitis anemia prior history
ndash Inadequate blood coagulation fetal death or DIC
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
Video youtubecomwatchv=jV6g427UMxYampfeature=related
McRoberts Maneuvers Video
Multiple Gestationbull Monozygotic (identical) twins can have 1 or 2 placentas
chorions or amnions (uarrrisk if all shared)bull Dizygotic (fraternal) twins 2 of everything
bull Dx faster than usual growth of uterus uarrAFP HCG Ultrasound
bull Risks bull Maternal SAB gestational DM HTNpreeclampsiaHELLP
hydramnios PT labor amp deliverybull Fetal Preterm birth twin-to-twin transfusion
Multiple Gestation (cont)bull Management
bull US to determine what type of twinsbull Prevention of PT laborroutine cervical measurements
(US)bull NST surveillance bull Birth depends on maternal amp fetal complications and
fetal position presentationbull Examination of placentabull Close monitoring PP for hemorrhage (atony)
Abruptio Placentaebull Premature separation of placenta from uterine wallbull SS sharp stabbing pain high in fundus heavy
bleeding (may be occult) hard board-like uterus tense painful uterus signs of shock due to blood loss Port-Wine aminotic fluid if ROM
bull Predisposing fx uarrparity adv maternal age short umbilical cord chronic HTN PIH direct trauma vasoconstriction from cocaine or cigarette use
bull Fetal distress on monitor Can progress to DIC
Abruptio Placentae (cont)bull Management
bull Emergency Immediate c-section if birth not imminent
bull Lg gauge IV bull O2 via mask fetal monitoring
maternal VS lateral positioning labs blood transfusion (have 2 units avail)
bull CBC (HampH) Fibrinogen levels platelet count PTPTT fibrin degradation products ( sx of DIC)
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
for pp hemorrhage
bull Table 26-6 pg 746 differential dx abruptioprevia
Low-lying Marginal
Partial Complete
Placenta Previas
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
Diabetes Pulmonary disease Pregnancy-induced hypertension)
bull Chorioamnionitisbull Suspected fetal problems- Intrauterine Growth
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Inductionbull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessmentbull Bishop Score- rating that determines if the cervix
is ready for induction--Pg 765bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole -Inadequate uterine relaxation between contractions lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveriesbull Forceps
bull Indications unable to push arrested descent need a quick delivery breech
bull Associated with maternalfetal birth trauma rectal sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
laborbull Elective
Placenta Factorsbull Placenta previabull Placental abruptionbull Umbilical cord prolapse
Fetal Factorsbull Breech transverse liebull Macrosomiabull Extreme low birth wtbull Fetal distressbull Fetal anomaliesbull Multiple gestation
Cesarean Birth (cont)bull Mortality
morbiditybull 4 x higher than
vaginal birth in US Most risk assoc with emergency c-section
bull Incisionbull Skin vs uterinebull Classical vs low
transverse
bull Maternal Complicationsbull Infectionbull Anesthesia reactionsbull DeepVeinThrombopheb
itisbull Bleedingbull Ureteralbladder injurybull Increase risk for
subsequent pregnancybull Placenta AcretaPrevia
Infertility
Cesarean Birthbull Pre-op CBC w platelets hold clotbull bicitraantacidbull monitor babybull Teaching pre amp post-op anesthesia recovery
breastfeedingbull Psychosocial issues
bull Fearbull Self-imageself-esteem
Post-Op Carebull Assess fundusbleeding vital signs DVTbull Antibiotics bull Pain Duramorph Breakthrough pain
meds Benadryl for itching Zofran for nausea
bull Clear liquids and advance as toleratedbull Assess for GI function Bowel sounds
Passing flatusbull Ambulation Pre-medicate teach splinting
with pillowbull Stool softener
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
multiparity excessive analgesia Afterpains wwwyoutubecomwatchv=EbItF_7KYCcampfeature=related
Fundal Assessment Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina Cervix returns to firm nongravid consistency
by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum Assessment turn pt to side in Simrsquos
position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments Constipation Give stool softeners as
ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis Superficial leg vein disease
ndash Ss tenderness in portion of vein local heat amp redness normal temperature or low-grade fever
ndash Tx local heat elevate limb bed rest analgesia elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation Engorgement day 3 or 4
ndash If breastfeeding Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
Postpartum Complications Postpartum Hemorrhage
ndash CAUSES Uterine atony lacerations retained placental fragments
Risk factorsndash uarr uterine distension multiples polyhydramnios
macrosomia fibroidsndash Trauma rapid or operative birthndash Placental problems previa accreta abruptio
retained placental fragmentsndash Atonic uterus prolonged pitocin magnesium
sulfate or labor uarr maternal age or parity uterine scar chorioamnionitis anemia prior history
ndash Inadequate blood coagulation fetal death or DIC
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
McRoberts Maneuvers Video
Multiple Gestationbull Monozygotic (identical) twins can have 1 or 2 placentas
chorions or amnions (uarrrisk if all shared)bull Dizygotic (fraternal) twins 2 of everything
bull Dx faster than usual growth of uterus uarrAFP HCG Ultrasound
bull Risks bull Maternal SAB gestational DM HTNpreeclampsiaHELLP
hydramnios PT labor amp deliverybull Fetal Preterm birth twin-to-twin transfusion
Multiple Gestation (cont)bull Management
bull US to determine what type of twinsbull Prevention of PT laborroutine cervical measurements
(US)bull NST surveillance bull Birth depends on maternal amp fetal complications and
fetal position presentationbull Examination of placentabull Close monitoring PP for hemorrhage (atony)
Abruptio Placentaebull Premature separation of placenta from uterine wallbull SS sharp stabbing pain high in fundus heavy
bleeding (may be occult) hard board-like uterus tense painful uterus signs of shock due to blood loss Port-Wine aminotic fluid if ROM
bull Predisposing fx uarrparity adv maternal age short umbilical cord chronic HTN PIH direct trauma vasoconstriction from cocaine or cigarette use
bull Fetal distress on monitor Can progress to DIC
Abruptio Placentae (cont)bull Management
bull Emergency Immediate c-section if birth not imminent
bull Lg gauge IV bull O2 via mask fetal monitoring
maternal VS lateral positioning labs blood transfusion (have 2 units avail)
bull CBC (HampH) Fibrinogen levels platelet count PTPTT fibrin degradation products ( sx of DIC)
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
for pp hemorrhage
bull Table 26-6 pg 746 differential dx abruptioprevia
Low-lying Marginal
Partial Complete
Placenta Previas
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
Diabetes Pulmonary disease Pregnancy-induced hypertension)
bull Chorioamnionitisbull Suspected fetal problems- Intrauterine Growth
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Inductionbull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessmentbull Bishop Score- rating that determines if the cervix
is ready for induction--Pg 765bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole -Inadequate uterine relaxation between contractions lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveriesbull Forceps
bull Indications unable to push arrested descent need a quick delivery breech
bull Associated with maternalfetal birth trauma rectal sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
laborbull Elective
Placenta Factorsbull Placenta previabull Placental abruptionbull Umbilical cord prolapse
Fetal Factorsbull Breech transverse liebull Macrosomiabull Extreme low birth wtbull Fetal distressbull Fetal anomaliesbull Multiple gestation
Cesarean Birth (cont)bull Mortality
morbiditybull 4 x higher than
vaginal birth in US Most risk assoc with emergency c-section
bull Incisionbull Skin vs uterinebull Classical vs low
transverse
bull Maternal Complicationsbull Infectionbull Anesthesia reactionsbull DeepVeinThrombopheb
itisbull Bleedingbull Ureteralbladder injurybull Increase risk for
subsequent pregnancybull Placenta AcretaPrevia
Infertility
Cesarean Birthbull Pre-op CBC w platelets hold clotbull bicitraantacidbull monitor babybull Teaching pre amp post-op anesthesia recovery
breastfeedingbull Psychosocial issues
bull Fearbull Self-imageself-esteem
Post-Op Carebull Assess fundusbleeding vital signs DVTbull Antibiotics bull Pain Duramorph Breakthrough pain
meds Benadryl for itching Zofran for nausea
bull Clear liquids and advance as toleratedbull Assess for GI function Bowel sounds
Passing flatusbull Ambulation Pre-medicate teach splinting
with pillowbull Stool softener
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
multiparity excessive analgesia Afterpains wwwyoutubecomwatchv=EbItF_7KYCcampfeature=related
Fundal Assessment Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina Cervix returns to firm nongravid consistency
by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum Assessment turn pt to side in Simrsquos
position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments Constipation Give stool softeners as
ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis Superficial leg vein disease
ndash Ss tenderness in portion of vein local heat amp redness normal temperature or low-grade fever
ndash Tx local heat elevate limb bed rest analgesia elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation Engorgement day 3 or 4
ndash If breastfeeding Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
Postpartum Complications Postpartum Hemorrhage
ndash CAUSES Uterine atony lacerations retained placental fragments
Risk factorsndash uarr uterine distension multiples polyhydramnios
macrosomia fibroidsndash Trauma rapid or operative birthndash Placental problems previa accreta abruptio
retained placental fragmentsndash Atonic uterus prolonged pitocin magnesium
sulfate or labor uarr maternal age or parity uterine scar chorioamnionitis anemia prior history
ndash Inadequate blood coagulation fetal death or DIC
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
Multiple Gestationbull Monozygotic (identical) twins can have 1 or 2 placentas
chorions or amnions (uarrrisk if all shared)bull Dizygotic (fraternal) twins 2 of everything
bull Dx faster than usual growth of uterus uarrAFP HCG Ultrasound
bull Risks bull Maternal SAB gestational DM HTNpreeclampsiaHELLP
hydramnios PT labor amp deliverybull Fetal Preterm birth twin-to-twin transfusion
Multiple Gestation (cont)bull Management
bull US to determine what type of twinsbull Prevention of PT laborroutine cervical measurements
(US)bull NST surveillance bull Birth depends on maternal amp fetal complications and
fetal position presentationbull Examination of placentabull Close monitoring PP for hemorrhage (atony)
Abruptio Placentaebull Premature separation of placenta from uterine wallbull SS sharp stabbing pain high in fundus heavy
bleeding (may be occult) hard board-like uterus tense painful uterus signs of shock due to blood loss Port-Wine aminotic fluid if ROM
bull Predisposing fx uarrparity adv maternal age short umbilical cord chronic HTN PIH direct trauma vasoconstriction from cocaine or cigarette use
bull Fetal distress on monitor Can progress to DIC
Abruptio Placentae (cont)bull Management
bull Emergency Immediate c-section if birth not imminent
bull Lg gauge IV bull O2 via mask fetal monitoring
maternal VS lateral positioning labs blood transfusion (have 2 units avail)
bull CBC (HampH) Fibrinogen levels platelet count PTPTT fibrin degradation products ( sx of DIC)
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
for pp hemorrhage
bull Table 26-6 pg 746 differential dx abruptioprevia
Low-lying Marginal
Partial Complete
Placenta Previas
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
Diabetes Pulmonary disease Pregnancy-induced hypertension)
bull Chorioamnionitisbull Suspected fetal problems- Intrauterine Growth
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Inductionbull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessmentbull Bishop Score- rating that determines if the cervix
is ready for induction--Pg 765bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole -Inadequate uterine relaxation between contractions lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveriesbull Forceps
bull Indications unable to push arrested descent need a quick delivery breech
bull Associated with maternalfetal birth trauma rectal sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
laborbull Elective
Placenta Factorsbull Placenta previabull Placental abruptionbull Umbilical cord prolapse
Fetal Factorsbull Breech transverse liebull Macrosomiabull Extreme low birth wtbull Fetal distressbull Fetal anomaliesbull Multiple gestation
Cesarean Birth (cont)bull Mortality
morbiditybull 4 x higher than
vaginal birth in US Most risk assoc with emergency c-section
bull Incisionbull Skin vs uterinebull Classical vs low
transverse
bull Maternal Complicationsbull Infectionbull Anesthesia reactionsbull DeepVeinThrombopheb
itisbull Bleedingbull Ureteralbladder injurybull Increase risk for
subsequent pregnancybull Placenta AcretaPrevia
Infertility
Cesarean Birthbull Pre-op CBC w platelets hold clotbull bicitraantacidbull monitor babybull Teaching pre amp post-op anesthesia recovery
breastfeedingbull Psychosocial issues
bull Fearbull Self-imageself-esteem
Post-Op Carebull Assess fundusbleeding vital signs DVTbull Antibiotics bull Pain Duramorph Breakthrough pain
meds Benadryl for itching Zofran for nausea
bull Clear liquids and advance as toleratedbull Assess for GI function Bowel sounds
Passing flatusbull Ambulation Pre-medicate teach splinting
with pillowbull Stool softener
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
multiparity excessive analgesia Afterpains wwwyoutubecomwatchv=EbItF_7KYCcampfeature=related
Fundal Assessment Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina Cervix returns to firm nongravid consistency
by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum Assessment turn pt to side in Simrsquos
position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments Constipation Give stool softeners as
ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis Superficial leg vein disease
ndash Ss tenderness in portion of vein local heat amp redness normal temperature or low-grade fever
ndash Tx local heat elevate limb bed rest analgesia elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation Engorgement day 3 or 4
ndash If breastfeeding Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
Postpartum Complications Postpartum Hemorrhage
ndash CAUSES Uterine atony lacerations retained placental fragments
Risk factorsndash uarr uterine distension multiples polyhydramnios
macrosomia fibroidsndash Trauma rapid or operative birthndash Placental problems previa accreta abruptio
retained placental fragmentsndash Atonic uterus prolonged pitocin magnesium
sulfate or labor uarr maternal age or parity uterine scar chorioamnionitis anemia prior history
ndash Inadequate blood coagulation fetal death or DIC
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
Multiple Gestation (cont)bull Management
bull US to determine what type of twinsbull Prevention of PT laborroutine cervical measurements
(US)bull NST surveillance bull Birth depends on maternal amp fetal complications and
fetal position presentationbull Examination of placentabull Close monitoring PP for hemorrhage (atony)
Abruptio Placentaebull Premature separation of placenta from uterine wallbull SS sharp stabbing pain high in fundus heavy
bleeding (may be occult) hard board-like uterus tense painful uterus signs of shock due to blood loss Port-Wine aminotic fluid if ROM
bull Predisposing fx uarrparity adv maternal age short umbilical cord chronic HTN PIH direct trauma vasoconstriction from cocaine or cigarette use
bull Fetal distress on monitor Can progress to DIC
Abruptio Placentae (cont)bull Management
bull Emergency Immediate c-section if birth not imminent
bull Lg gauge IV bull O2 via mask fetal monitoring
maternal VS lateral positioning labs blood transfusion (have 2 units avail)
bull CBC (HampH) Fibrinogen levels platelet count PTPTT fibrin degradation products ( sx of DIC)
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
for pp hemorrhage
bull Table 26-6 pg 746 differential dx abruptioprevia
Low-lying Marginal
Partial Complete
Placenta Previas
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
Diabetes Pulmonary disease Pregnancy-induced hypertension)
bull Chorioamnionitisbull Suspected fetal problems- Intrauterine Growth
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Inductionbull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessmentbull Bishop Score- rating that determines if the cervix
is ready for induction--Pg 765bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole -Inadequate uterine relaxation between contractions lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveriesbull Forceps
bull Indications unable to push arrested descent need a quick delivery breech
bull Associated with maternalfetal birth trauma rectal sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
laborbull Elective
Placenta Factorsbull Placenta previabull Placental abruptionbull Umbilical cord prolapse
Fetal Factorsbull Breech transverse liebull Macrosomiabull Extreme low birth wtbull Fetal distressbull Fetal anomaliesbull Multiple gestation
Cesarean Birth (cont)bull Mortality
morbiditybull 4 x higher than
vaginal birth in US Most risk assoc with emergency c-section
bull Incisionbull Skin vs uterinebull Classical vs low
transverse
bull Maternal Complicationsbull Infectionbull Anesthesia reactionsbull DeepVeinThrombopheb
itisbull Bleedingbull Ureteralbladder injurybull Increase risk for
subsequent pregnancybull Placenta AcretaPrevia
Infertility
Cesarean Birthbull Pre-op CBC w platelets hold clotbull bicitraantacidbull monitor babybull Teaching pre amp post-op anesthesia recovery
breastfeedingbull Psychosocial issues
bull Fearbull Self-imageself-esteem
Post-Op Carebull Assess fundusbleeding vital signs DVTbull Antibiotics bull Pain Duramorph Breakthrough pain
meds Benadryl for itching Zofran for nausea
bull Clear liquids and advance as toleratedbull Assess for GI function Bowel sounds
Passing flatusbull Ambulation Pre-medicate teach splinting
with pillowbull Stool softener
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
multiparity excessive analgesia Afterpains wwwyoutubecomwatchv=EbItF_7KYCcampfeature=related
Fundal Assessment Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina Cervix returns to firm nongravid consistency
by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum Assessment turn pt to side in Simrsquos
position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments Constipation Give stool softeners as
ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis Superficial leg vein disease
ndash Ss tenderness in portion of vein local heat amp redness normal temperature or low-grade fever
ndash Tx local heat elevate limb bed rest analgesia elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation Engorgement day 3 or 4
ndash If breastfeeding Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
Postpartum Complications Postpartum Hemorrhage
ndash CAUSES Uterine atony lacerations retained placental fragments
Risk factorsndash uarr uterine distension multiples polyhydramnios
macrosomia fibroidsndash Trauma rapid or operative birthndash Placental problems previa accreta abruptio
retained placental fragmentsndash Atonic uterus prolonged pitocin magnesium
sulfate or labor uarr maternal age or parity uterine scar chorioamnionitis anemia prior history
ndash Inadequate blood coagulation fetal death or DIC
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
Abruptio Placentaebull Premature separation of placenta from uterine wallbull SS sharp stabbing pain high in fundus heavy
bleeding (may be occult) hard board-like uterus tense painful uterus signs of shock due to blood loss Port-Wine aminotic fluid if ROM
bull Predisposing fx uarrparity adv maternal age short umbilical cord chronic HTN PIH direct trauma vasoconstriction from cocaine or cigarette use
bull Fetal distress on monitor Can progress to DIC
Abruptio Placentae (cont)bull Management
bull Emergency Immediate c-section if birth not imminent
bull Lg gauge IV bull O2 via mask fetal monitoring
maternal VS lateral positioning labs blood transfusion (have 2 units avail)
bull CBC (HampH) Fibrinogen levels platelet count PTPTT fibrin degradation products ( sx of DIC)
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
for pp hemorrhage
bull Table 26-6 pg 746 differential dx abruptioprevia
Low-lying Marginal
Partial Complete
Placenta Previas
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
Diabetes Pulmonary disease Pregnancy-induced hypertension)
bull Chorioamnionitisbull Suspected fetal problems- Intrauterine Growth
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Inductionbull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessmentbull Bishop Score- rating that determines if the cervix
is ready for induction--Pg 765bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole -Inadequate uterine relaxation between contractions lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveriesbull Forceps
bull Indications unable to push arrested descent need a quick delivery breech
bull Associated with maternalfetal birth trauma rectal sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
laborbull Elective
Placenta Factorsbull Placenta previabull Placental abruptionbull Umbilical cord prolapse
Fetal Factorsbull Breech transverse liebull Macrosomiabull Extreme low birth wtbull Fetal distressbull Fetal anomaliesbull Multiple gestation
Cesarean Birth (cont)bull Mortality
morbiditybull 4 x higher than
vaginal birth in US Most risk assoc with emergency c-section
bull Incisionbull Skin vs uterinebull Classical vs low
transverse
bull Maternal Complicationsbull Infectionbull Anesthesia reactionsbull DeepVeinThrombopheb
itisbull Bleedingbull Ureteralbladder injurybull Increase risk for
subsequent pregnancybull Placenta AcretaPrevia
Infertility
Cesarean Birthbull Pre-op CBC w platelets hold clotbull bicitraantacidbull monitor babybull Teaching pre amp post-op anesthesia recovery
breastfeedingbull Psychosocial issues
bull Fearbull Self-imageself-esteem
Post-Op Carebull Assess fundusbleeding vital signs DVTbull Antibiotics bull Pain Duramorph Breakthrough pain
meds Benadryl for itching Zofran for nausea
bull Clear liquids and advance as toleratedbull Assess for GI function Bowel sounds
Passing flatusbull Ambulation Pre-medicate teach splinting
with pillowbull Stool softener
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
multiparity excessive analgesia Afterpains wwwyoutubecomwatchv=EbItF_7KYCcampfeature=related
Fundal Assessment Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina Cervix returns to firm nongravid consistency
by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum Assessment turn pt to side in Simrsquos
position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments Constipation Give stool softeners as
ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis Superficial leg vein disease
ndash Ss tenderness in portion of vein local heat amp redness normal temperature or low-grade fever
ndash Tx local heat elevate limb bed rest analgesia elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation Engorgement day 3 or 4
ndash If breastfeeding Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
Postpartum Complications Postpartum Hemorrhage
ndash CAUSES Uterine atony lacerations retained placental fragments
Risk factorsndash uarr uterine distension multiples polyhydramnios
macrosomia fibroidsndash Trauma rapid or operative birthndash Placental problems previa accreta abruptio
retained placental fragmentsndash Atonic uterus prolonged pitocin magnesium
sulfate or labor uarr maternal age or parity uterine scar chorioamnionitis anemia prior history
ndash Inadequate blood coagulation fetal death or DIC
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
Abruptio Placentae (cont)bull Management
bull Emergency Immediate c-section if birth not imminent
bull Lg gauge IV bull O2 via mask fetal monitoring
maternal VS lateral positioning labs blood transfusion (have 2 units avail)
bull CBC (HampH) Fibrinogen levels platelet count PTPTT fibrin degradation products ( sx of DIC)
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
for pp hemorrhage
bull Table 26-6 pg 746 differential dx abruptioprevia
Low-lying Marginal
Partial Complete
Placenta Previas
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
Diabetes Pulmonary disease Pregnancy-induced hypertension)
bull Chorioamnionitisbull Suspected fetal problems- Intrauterine Growth
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Inductionbull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessmentbull Bishop Score- rating that determines if the cervix
is ready for induction--Pg 765bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole -Inadequate uterine relaxation between contractions lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveriesbull Forceps
bull Indications unable to push arrested descent need a quick delivery breech
bull Associated with maternalfetal birth trauma rectal sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
laborbull Elective
Placenta Factorsbull Placenta previabull Placental abruptionbull Umbilical cord prolapse
Fetal Factorsbull Breech transverse liebull Macrosomiabull Extreme low birth wtbull Fetal distressbull Fetal anomaliesbull Multiple gestation
Cesarean Birth (cont)bull Mortality
morbiditybull 4 x higher than
vaginal birth in US Most risk assoc with emergency c-section
bull Incisionbull Skin vs uterinebull Classical vs low
transverse
bull Maternal Complicationsbull Infectionbull Anesthesia reactionsbull DeepVeinThrombopheb
itisbull Bleedingbull Ureteralbladder injurybull Increase risk for
subsequent pregnancybull Placenta AcretaPrevia
Infertility
Cesarean Birthbull Pre-op CBC w platelets hold clotbull bicitraantacidbull monitor babybull Teaching pre amp post-op anesthesia recovery
breastfeedingbull Psychosocial issues
bull Fearbull Self-imageself-esteem
Post-Op Carebull Assess fundusbleeding vital signs DVTbull Antibiotics bull Pain Duramorph Breakthrough pain
meds Benadryl for itching Zofran for nausea
bull Clear liquids and advance as toleratedbull Assess for GI function Bowel sounds
Passing flatusbull Ambulation Pre-medicate teach splinting
with pillowbull Stool softener
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
multiparity excessive analgesia Afterpains wwwyoutubecomwatchv=EbItF_7KYCcampfeature=related
Fundal Assessment Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina Cervix returns to firm nongravid consistency
by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum Assessment turn pt to side in Simrsquos
position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments Constipation Give stool softeners as
ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis Superficial leg vein disease
ndash Ss tenderness in portion of vein local heat amp redness normal temperature or low-grade fever
ndash Tx local heat elevate limb bed rest analgesia elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation Engorgement day 3 or 4
ndash If breastfeeding Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
Postpartum Complications Postpartum Hemorrhage
ndash CAUSES Uterine atony lacerations retained placental fragments
Risk factorsndash uarr uterine distension multiples polyhydramnios
macrosomia fibroidsndash Trauma rapid or operative birthndash Placental problems previa accreta abruptio
retained placental fragmentsndash Atonic uterus prolonged pitocin magnesium
sulfate or labor uarr maternal age or parity uterine scar chorioamnionitis anemia prior history
ndash Inadequate blood coagulation fetal death or DIC
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
for pp hemorrhage
bull Table 26-6 pg 746 differential dx abruptioprevia
Low-lying Marginal
Partial Complete
Placenta Previas
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
Diabetes Pulmonary disease Pregnancy-induced hypertension)
bull Chorioamnionitisbull Suspected fetal problems- Intrauterine Growth
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Inductionbull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessmentbull Bishop Score- rating that determines if the cervix
is ready for induction--Pg 765bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole -Inadequate uterine relaxation between contractions lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveriesbull Forceps
bull Indications unable to push arrested descent need a quick delivery breech
bull Associated with maternalfetal birth trauma rectal sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
laborbull Elective
Placenta Factorsbull Placenta previabull Placental abruptionbull Umbilical cord prolapse
Fetal Factorsbull Breech transverse liebull Macrosomiabull Extreme low birth wtbull Fetal distressbull Fetal anomaliesbull Multiple gestation
Cesarean Birth (cont)bull Mortality
morbiditybull 4 x higher than
vaginal birth in US Most risk assoc with emergency c-section
bull Incisionbull Skin vs uterinebull Classical vs low
transverse
bull Maternal Complicationsbull Infectionbull Anesthesia reactionsbull DeepVeinThrombopheb
itisbull Bleedingbull Ureteralbladder injurybull Increase risk for
subsequent pregnancybull Placenta AcretaPrevia
Infertility
Cesarean Birthbull Pre-op CBC w platelets hold clotbull bicitraantacidbull monitor babybull Teaching pre amp post-op anesthesia recovery
breastfeedingbull Psychosocial issues
bull Fearbull Self-imageself-esteem
Post-Op Carebull Assess fundusbleeding vital signs DVTbull Antibiotics bull Pain Duramorph Breakthrough pain
meds Benadryl for itching Zofran for nausea
bull Clear liquids and advance as toleratedbull Assess for GI function Bowel sounds
Passing flatusbull Ambulation Pre-medicate teach splinting
with pillowbull Stool softener
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
multiparity excessive analgesia Afterpains wwwyoutubecomwatchv=EbItF_7KYCcampfeature=related
Fundal Assessment Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina Cervix returns to firm nongravid consistency
by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum Assessment turn pt to side in Simrsquos
position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments Constipation Give stool softeners as
ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis Superficial leg vein disease
ndash Ss tenderness in portion of vein local heat amp redness normal temperature or low-grade fever
ndash Tx local heat elevate limb bed rest analgesia elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation Engorgement day 3 or 4
ndash If breastfeeding Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
Postpartum Complications Postpartum Hemorrhage
ndash CAUSES Uterine atony lacerations retained placental fragments
Risk factorsndash uarr uterine distension multiples polyhydramnios
macrosomia fibroidsndash Trauma rapid or operative birthndash Placental problems previa accreta abruptio
retained placental fragmentsndash Atonic uterus prolonged pitocin magnesium
sulfate or labor uarr maternal age or parity uterine scar chorioamnionitis anemia prior history
ndash Inadequate blood coagulation fetal death or DIC
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
Low-lying Marginal
Partial Complete
Placenta Previas
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
Diabetes Pulmonary disease Pregnancy-induced hypertension)
bull Chorioamnionitisbull Suspected fetal problems- Intrauterine Growth
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Inductionbull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessmentbull Bishop Score- rating that determines if the cervix
is ready for induction--Pg 765bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole -Inadequate uterine relaxation between contractions lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveriesbull Forceps
bull Indications unable to push arrested descent need a quick delivery breech
bull Associated with maternalfetal birth trauma rectal sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
laborbull Elective
Placenta Factorsbull Placenta previabull Placental abruptionbull Umbilical cord prolapse
Fetal Factorsbull Breech transverse liebull Macrosomiabull Extreme low birth wtbull Fetal distressbull Fetal anomaliesbull Multiple gestation
Cesarean Birth (cont)bull Mortality
morbiditybull 4 x higher than
vaginal birth in US Most risk assoc with emergency c-section
bull Incisionbull Skin vs uterinebull Classical vs low
transverse
bull Maternal Complicationsbull Infectionbull Anesthesia reactionsbull DeepVeinThrombopheb
itisbull Bleedingbull Ureteralbladder injurybull Increase risk for
subsequent pregnancybull Placenta AcretaPrevia
Infertility
Cesarean Birthbull Pre-op CBC w platelets hold clotbull bicitraantacidbull monitor babybull Teaching pre amp post-op anesthesia recovery
breastfeedingbull Psychosocial issues
bull Fearbull Self-imageself-esteem
Post-Op Carebull Assess fundusbleeding vital signs DVTbull Antibiotics bull Pain Duramorph Breakthrough pain
meds Benadryl for itching Zofran for nausea
bull Clear liquids and advance as toleratedbull Assess for GI function Bowel sounds
Passing flatusbull Ambulation Pre-medicate teach splinting
with pillowbull Stool softener
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
multiparity excessive analgesia Afterpains wwwyoutubecomwatchv=EbItF_7KYCcampfeature=related
Fundal Assessment Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina Cervix returns to firm nongravid consistency
by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum Assessment turn pt to side in Simrsquos
position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments Constipation Give stool softeners as
ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis Superficial leg vein disease
ndash Ss tenderness in portion of vein local heat amp redness normal temperature or low-grade fever
ndash Tx local heat elevate limb bed rest analgesia elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation Engorgement day 3 or 4
ndash If breastfeeding Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
Postpartum Complications Postpartum Hemorrhage
ndash CAUSES Uterine atony lacerations retained placental fragments
Risk factorsndash uarr uterine distension multiples polyhydramnios
macrosomia fibroidsndash Trauma rapid or operative birthndash Placental problems previa accreta abruptio
retained placental fragmentsndash Atonic uterus prolonged pitocin magnesium
sulfate or labor uarr maternal age or parity uterine scar chorioamnionitis anemia prior history
ndash Inadequate blood coagulation fetal death or DIC
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
Diabetes Pulmonary disease Pregnancy-induced hypertension)
bull Chorioamnionitisbull Suspected fetal problems- Intrauterine Growth
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Inductionbull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessmentbull Bishop Score- rating that determines if the cervix
is ready for induction--Pg 765bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole -Inadequate uterine relaxation between contractions lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveriesbull Forceps
bull Indications unable to push arrested descent need a quick delivery breech
bull Associated with maternalfetal birth trauma rectal sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
laborbull Elective
Placenta Factorsbull Placenta previabull Placental abruptionbull Umbilical cord prolapse
Fetal Factorsbull Breech transverse liebull Macrosomiabull Extreme low birth wtbull Fetal distressbull Fetal anomaliesbull Multiple gestation
Cesarean Birth (cont)bull Mortality
morbiditybull 4 x higher than
vaginal birth in US Most risk assoc with emergency c-section
bull Incisionbull Skin vs uterinebull Classical vs low
transverse
bull Maternal Complicationsbull Infectionbull Anesthesia reactionsbull DeepVeinThrombopheb
itisbull Bleedingbull Ureteralbladder injurybull Increase risk for
subsequent pregnancybull Placenta AcretaPrevia
Infertility
Cesarean Birthbull Pre-op CBC w platelets hold clotbull bicitraantacidbull monitor babybull Teaching pre amp post-op anesthesia recovery
breastfeedingbull Psychosocial issues
bull Fearbull Self-imageself-esteem
Post-Op Carebull Assess fundusbleeding vital signs DVTbull Antibiotics bull Pain Duramorph Breakthrough pain
meds Benadryl for itching Zofran for nausea
bull Clear liquids and advance as toleratedbull Assess for GI function Bowel sounds
Passing flatusbull Ambulation Pre-medicate teach splinting
with pillowbull Stool softener
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
multiparity excessive analgesia Afterpains wwwyoutubecomwatchv=EbItF_7KYCcampfeature=related
Fundal Assessment Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina Cervix returns to firm nongravid consistency
by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum Assessment turn pt to side in Simrsquos
position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments Constipation Give stool softeners as
ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis Superficial leg vein disease
ndash Ss tenderness in portion of vein local heat amp redness normal temperature or low-grade fever
ndash Tx local heat elevate limb bed rest analgesia elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation Engorgement day 3 or 4
ndash If breastfeeding Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
Postpartum Complications Postpartum Hemorrhage
ndash CAUSES Uterine atony lacerations retained placental fragments
Risk factorsndash uarr uterine distension multiples polyhydramnios
macrosomia fibroidsndash Trauma rapid or operative birthndash Placental problems previa accreta abruptio
retained placental fragmentsndash Atonic uterus prolonged pitocin magnesium
sulfate or labor uarr maternal age or parity uterine scar chorioamnionitis anemia prior history
ndash Inadequate blood coagulation fetal death or DIC
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
Diabetes Pulmonary disease Pregnancy-induced hypertension)
bull Chorioamnionitisbull Suspected fetal problems- Intrauterine Growth
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Inductionbull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessmentbull Bishop Score- rating that determines if the cervix
is ready for induction--Pg 765bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole -Inadequate uterine relaxation between contractions lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveriesbull Forceps
bull Indications unable to push arrested descent need a quick delivery breech
bull Associated with maternalfetal birth trauma rectal sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
laborbull Elective
Placenta Factorsbull Placenta previabull Placental abruptionbull Umbilical cord prolapse
Fetal Factorsbull Breech transverse liebull Macrosomiabull Extreme low birth wtbull Fetal distressbull Fetal anomaliesbull Multiple gestation
Cesarean Birth (cont)bull Mortality
morbiditybull 4 x higher than
vaginal birth in US Most risk assoc with emergency c-section
bull Incisionbull Skin vs uterinebull Classical vs low
transverse
bull Maternal Complicationsbull Infectionbull Anesthesia reactionsbull DeepVeinThrombopheb
itisbull Bleedingbull Ureteralbladder injurybull Increase risk for
subsequent pregnancybull Placenta AcretaPrevia
Infertility
Cesarean Birthbull Pre-op CBC w platelets hold clotbull bicitraantacidbull monitor babybull Teaching pre amp post-op anesthesia recovery
breastfeedingbull Psychosocial issues
bull Fearbull Self-imageself-esteem
Post-Op Carebull Assess fundusbleeding vital signs DVTbull Antibiotics bull Pain Duramorph Breakthrough pain
meds Benadryl for itching Zofran for nausea
bull Clear liquids and advance as toleratedbull Assess for GI function Bowel sounds
Passing flatusbull Ambulation Pre-medicate teach splinting
with pillowbull Stool softener
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
multiparity excessive analgesia Afterpains wwwyoutubecomwatchv=EbItF_7KYCcampfeature=related
Fundal Assessment Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina Cervix returns to firm nongravid consistency
by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum Assessment turn pt to side in Simrsquos
position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments Constipation Give stool softeners as
ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis Superficial leg vein disease
ndash Ss tenderness in portion of vein local heat amp redness normal temperature or low-grade fever
ndash Tx local heat elevate limb bed rest analgesia elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation Engorgement day 3 or 4
ndash If breastfeeding Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
Postpartum Complications Postpartum Hemorrhage
ndash CAUSES Uterine atony lacerations retained placental fragments
Risk factorsndash uarr uterine distension multiples polyhydramnios
macrosomia fibroidsndash Trauma rapid or operative birthndash Placental problems previa accreta abruptio
retained placental fragmentsndash Atonic uterus prolonged pitocin magnesium
sulfate or labor uarr maternal age or parity uterine scar chorioamnionitis anemia prior history
ndash Inadequate blood coagulation fetal death or DIC
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
Diabetes Pulmonary disease Pregnancy-induced hypertension)
bull Chorioamnionitisbull Suspected fetal problems- Intrauterine Growth
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Inductionbull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessmentbull Bishop Score- rating that determines if the cervix
is ready for induction--Pg 765bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole -Inadequate uterine relaxation between contractions lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveriesbull Forceps
bull Indications unable to push arrested descent need a quick delivery breech
bull Associated with maternalfetal birth trauma rectal sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
laborbull Elective
Placenta Factorsbull Placenta previabull Placental abruptionbull Umbilical cord prolapse
Fetal Factorsbull Breech transverse liebull Macrosomiabull Extreme low birth wtbull Fetal distressbull Fetal anomaliesbull Multiple gestation
Cesarean Birth (cont)bull Mortality
morbiditybull 4 x higher than
vaginal birth in US Most risk assoc with emergency c-section
bull Incisionbull Skin vs uterinebull Classical vs low
transverse
bull Maternal Complicationsbull Infectionbull Anesthesia reactionsbull DeepVeinThrombopheb
itisbull Bleedingbull Ureteralbladder injurybull Increase risk for
subsequent pregnancybull Placenta AcretaPrevia
Infertility
Cesarean Birthbull Pre-op CBC w platelets hold clotbull bicitraantacidbull monitor babybull Teaching pre amp post-op anesthesia recovery
breastfeedingbull Psychosocial issues
bull Fearbull Self-imageself-esteem
Post-Op Carebull Assess fundusbleeding vital signs DVTbull Antibiotics bull Pain Duramorph Breakthrough pain
meds Benadryl for itching Zofran for nausea
bull Clear liquids and advance as toleratedbull Assess for GI function Bowel sounds
Passing flatusbull Ambulation Pre-medicate teach splinting
with pillowbull Stool softener
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
multiparity excessive analgesia Afterpains wwwyoutubecomwatchv=EbItF_7KYCcampfeature=related
Fundal Assessment Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina Cervix returns to firm nongravid consistency
by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum Assessment turn pt to side in Simrsquos
position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments Constipation Give stool softeners as
ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis Superficial leg vein disease
ndash Ss tenderness in portion of vein local heat amp redness normal temperature or low-grade fever
ndash Tx local heat elevate limb bed rest analgesia elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation Engorgement day 3 or 4
ndash If breastfeeding Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
Postpartum Complications Postpartum Hemorrhage
ndash CAUSES Uterine atony lacerations retained placental fragments
Risk factorsndash uarr uterine distension multiples polyhydramnios
macrosomia fibroidsndash Trauma rapid or operative birthndash Placental problems previa accreta abruptio
retained placental fragmentsndash Atonic uterus prolonged pitocin magnesium
sulfate or labor uarr maternal age or parity uterine scar chorioamnionitis anemia prior history
ndash Inadequate blood coagulation fetal death or DIC
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
Diabetes Pulmonary disease Pregnancy-induced hypertension)
bull Chorioamnionitisbull Suspected fetal problems- Intrauterine Growth
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Inductionbull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessmentbull Bishop Score- rating that determines if the cervix
is ready for induction--Pg 765bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole -Inadequate uterine relaxation between contractions lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveriesbull Forceps
bull Indications unable to push arrested descent need a quick delivery breech
bull Associated with maternalfetal birth trauma rectal sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
laborbull Elective
Placenta Factorsbull Placenta previabull Placental abruptionbull Umbilical cord prolapse
Fetal Factorsbull Breech transverse liebull Macrosomiabull Extreme low birth wtbull Fetal distressbull Fetal anomaliesbull Multiple gestation
Cesarean Birth (cont)bull Mortality
morbiditybull 4 x higher than
vaginal birth in US Most risk assoc with emergency c-section
bull Incisionbull Skin vs uterinebull Classical vs low
transverse
bull Maternal Complicationsbull Infectionbull Anesthesia reactionsbull DeepVeinThrombopheb
itisbull Bleedingbull Ureteralbladder injurybull Increase risk for
subsequent pregnancybull Placenta AcretaPrevia
Infertility
Cesarean Birthbull Pre-op CBC w platelets hold clotbull bicitraantacidbull monitor babybull Teaching pre amp post-op anesthesia recovery
breastfeedingbull Psychosocial issues
bull Fearbull Self-imageself-esteem
Post-Op Carebull Assess fundusbleeding vital signs DVTbull Antibiotics bull Pain Duramorph Breakthrough pain
meds Benadryl for itching Zofran for nausea
bull Clear liquids and advance as toleratedbull Assess for GI function Bowel sounds
Passing flatusbull Ambulation Pre-medicate teach splinting
with pillowbull Stool softener
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
multiparity excessive analgesia Afterpains wwwyoutubecomwatchv=EbItF_7KYCcampfeature=related
Fundal Assessment Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina Cervix returns to firm nongravid consistency
by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum Assessment turn pt to side in Simrsquos
position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments Constipation Give stool softeners as
ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis Superficial leg vein disease
ndash Ss tenderness in portion of vein local heat amp redness normal temperature or low-grade fever
ndash Tx local heat elevate limb bed rest analgesia elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation Engorgement day 3 or 4
ndash If breastfeeding Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
Postpartum Complications Postpartum Hemorrhage
ndash CAUSES Uterine atony lacerations retained placental fragments
Risk factorsndash uarr uterine distension multiples polyhydramnios
macrosomia fibroidsndash Trauma rapid or operative birthndash Placental problems previa accreta abruptio
retained placental fragmentsndash Atonic uterus prolonged pitocin magnesium
sulfate or labor uarr maternal age or parity uterine scar chorioamnionitis anemia prior history
ndash Inadequate blood coagulation fetal death or DIC
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
Diabetes Pulmonary disease Pregnancy-induced hypertension)
bull Chorioamnionitisbull Suspected fetal problems- Intrauterine Growth
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Inductionbull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessmentbull Bishop Score- rating that determines if the cervix
is ready for induction--Pg 765bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole -Inadequate uterine relaxation between contractions lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveriesbull Forceps
bull Indications unable to push arrested descent need a quick delivery breech
bull Associated with maternalfetal birth trauma rectal sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
laborbull Elective
Placenta Factorsbull Placenta previabull Placental abruptionbull Umbilical cord prolapse
Fetal Factorsbull Breech transverse liebull Macrosomiabull Extreme low birth wtbull Fetal distressbull Fetal anomaliesbull Multiple gestation
Cesarean Birth (cont)bull Mortality
morbiditybull 4 x higher than
vaginal birth in US Most risk assoc with emergency c-section
bull Incisionbull Skin vs uterinebull Classical vs low
transverse
bull Maternal Complicationsbull Infectionbull Anesthesia reactionsbull DeepVeinThrombopheb
itisbull Bleedingbull Ureteralbladder injurybull Increase risk for
subsequent pregnancybull Placenta AcretaPrevia
Infertility
Cesarean Birthbull Pre-op CBC w platelets hold clotbull bicitraantacidbull monitor babybull Teaching pre amp post-op anesthesia recovery
breastfeedingbull Psychosocial issues
bull Fearbull Self-imageself-esteem
Post-Op Carebull Assess fundusbleeding vital signs DVTbull Antibiotics bull Pain Duramorph Breakthrough pain
meds Benadryl for itching Zofran for nausea
bull Clear liquids and advance as toleratedbull Assess for GI function Bowel sounds
Passing flatusbull Ambulation Pre-medicate teach splinting
with pillowbull Stool softener
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
multiparity excessive analgesia Afterpains wwwyoutubecomwatchv=EbItF_7KYCcampfeature=related
Fundal Assessment Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina Cervix returns to firm nongravid consistency
by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum Assessment turn pt to side in Simrsquos
position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments Constipation Give stool softeners as
ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis Superficial leg vein disease
ndash Ss tenderness in portion of vein local heat amp redness normal temperature or low-grade fever
ndash Tx local heat elevate limb bed rest analgesia elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation Engorgement day 3 or 4
ndash If breastfeeding Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
Postpartum Complications Postpartum Hemorrhage
ndash CAUSES Uterine atony lacerations retained placental fragments
Risk factorsndash uarr uterine distension multiples polyhydramnios
macrosomia fibroidsndash Trauma rapid or operative birthndash Placental problems previa accreta abruptio
retained placental fragmentsndash Atonic uterus prolonged pitocin magnesium
sulfate or labor uarr maternal age or parity uterine scar chorioamnionitis anemia prior history
ndash Inadequate blood coagulation fetal death or DIC
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
Contraindications to Inductionbull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessmentbull Bishop Score- rating that determines if the cervix
is ready for induction--Pg 765bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole -Inadequate uterine relaxation between contractions lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveriesbull Forceps
bull Indications unable to push arrested descent need a quick delivery breech
bull Associated with maternalfetal birth trauma rectal sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
laborbull Elective
Placenta Factorsbull Placenta previabull Placental abruptionbull Umbilical cord prolapse
Fetal Factorsbull Breech transverse liebull Macrosomiabull Extreme low birth wtbull Fetal distressbull Fetal anomaliesbull Multiple gestation
Cesarean Birth (cont)bull Mortality
morbiditybull 4 x higher than
vaginal birth in US Most risk assoc with emergency c-section
bull Incisionbull Skin vs uterinebull Classical vs low
transverse
bull Maternal Complicationsbull Infectionbull Anesthesia reactionsbull DeepVeinThrombopheb
itisbull Bleedingbull Ureteralbladder injurybull Increase risk for
subsequent pregnancybull Placenta AcretaPrevia
Infertility
Cesarean Birthbull Pre-op CBC w platelets hold clotbull bicitraantacidbull monitor babybull Teaching pre amp post-op anesthesia recovery
breastfeedingbull Psychosocial issues
bull Fearbull Self-imageself-esteem
Post-Op Carebull Assess fundusbleeding vital signs DVTbull Antibiotics bull Pain Duramorph Breakthrough pain
meds Benadryl for itching Zofran for nausea
bull Clear liquids and advance as toleratedbull Assess for GI function Bowel sounds
Passing flatusbull Ambulation Pre-medicate teach splinting
with pillowbull Stool softener
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
multiparity excessive analgesia Afterpains wwwyoutubecomwatchv=EbItF_7KYCcampfeature=related
Fundal Assessment Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina Cervix returns to firm nongravid consistency
by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum Assessment turn pt to side in Simrsquos
position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments Constipation Give stool softeners as
ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis Superficial leg vein disease
ndash Ss tenderness in portion of vein local heat amp redness normal temperature or low-grade fever
ndash Tx local heat elevate limb bed rest analgesia elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation Engorgement day 3 or 4
ndash If breastfeeding Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
Postpartum Complications Postpartum Hemorrhage
ndash CAUSES Uterine atony lacerations retained placental fragments
Risk factorsndash uarr uterine distension multiples polyhydramnios
macrosomia fibroidsndash Trauma rapid or operative birthndash Placental problems previa accreta abruptio
retained placental fragmentsndash Atonic uterus prolonged pitocin magnesium
sulfate or labor uarr maternal age or parity uterine scar chorioamnionitis anemia prior history
ndash Inadequate blood coagulation fetal death or DIC
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
Cervical Ripening Assessmentbull Bishop Score- rating that determines if the cervix
is ready for induction--Pg 765bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole -Inadequate uterine relaxation between contractions lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveriesbull Forceps
bull Indications unable to push arrested descent need a quick delivery breech
bull Associated with maternalfetal birth trauma rectal sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
laborbull Elective
Placenta Factorsbull Placenta previabull Placental abruptionbull Umbilical cord prolapse
Fetal Factorsbull Breech transverse liebull Macrosomiabull Extreme low birth wtbull Fetal distressbull Fetal anomaliesbull Multiple gestation
Cesarean Birth (cont)bull Mortality
morbiditybull 4 x higher than
vaginal birth in US Most risk assoc with emergency c-section
bull Incisionbull Skin vs uterinebull Classical vs low
transverse
bull Maternal Complicationsbull Infectionbull Anesthesia reactionsbull DeepVeinThrombopheb
itisbull Bleedingbull Ureteralbladder injurybull Increase risk for
subsequent pregnancybull Placenta AcretaPrevia
Infertility
Cesarean Birthbull Pre-op CBC w platelets hold clotbull bicitraantacidbull monitor babybull Teaching pre amp post-op anesthesia recovery
breastfeedingbull Psychosocial issues
bull Fearbull Self-imageself-esteem
Post-Op Carebull Assess fundusbleeding vital signs DVTbull Antibiotics bull Pain Duramorph Breakthrough pain
meds Benadryl for itching Zofran for nausea
bull Clear liquids and advance as toleratedbull Assess for GI function Bowel sounds
Passing flatusbull Ambulation Pre-medicate teach splinting
with pillowbull Stool softener
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
multiparity excessive analgesia Afterpains wwwyoutubecomwatchv=EbItF_7KYCcampfeature=related
Fundal Assessment Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina Cervix returns to firm nongravid consistency
by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum Assessment turn pt to side in Simrsquos
position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments Constipation Give stool softeners as
ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis Superficial leg vein disease
ndash Ss tenderness in portion of vein local heat amp redness normal temperature or low-grade fever
ndash Tx local heat elevate limb bed rest analgesia elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation Engorgement day 3 or 4
ndash If breastfeeding Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
Postpartum Complications Postpartum Hemorrhage
ndash CAUSES Uterine atony lacerations retained placental fragments
Risk factorsndash uarr uterine distension multiples polyhydramnios
macrosomia fibroidsndash Trauma rapid or operative birthndash Placental problems previa accreta abruptio
retained placental fragmentsndash Atonic uterus prolonged pitocin magnesium
sulfate or labor uarr maternal age or parity uterine scar chorioamnionitis anemia prior history
ndash Inadequate blood coagulation fetal death or DIC
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole -Inadequate uterine relaxation between contractions lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveriesbull Forceps
bull Indications unable to push arrested descent need a quick delivery breech
bull Associated with maternalfetal birth trauma rectal sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
laborbull Elective
Placenta Factorsbull Placenta previabull Placental abruptionbull Umbilical cord prolapse
Fetal Factorsbull Breech transverse liebull Macrosomiabull Extreme low birth wtbull Fetal distressbull Fetal anomaliesbull Multiple gestation
Cesarean Birth (cont)bull Mortality
morbiditybull 4 x higher than
vaginal birth in US Most risk assoc with emergency c-section
bull Incisionbull Skin vs uterinebull Classical vs low
transverse
bull Maternal Complicationsbull Infectionbull Anesthesia reactionsbull DeepVeinThrombopheb
itisbull Bleedingbull Ureteralbladder injurybull Increase risk for
subsequent pregnancybull Placenta AcretaPrevia
Infertility
Cesarean Birthbull Pre-op CBC w platelets hold clotbull bicitraantacidbull monitor babybull Teaching pre amp post-op anesthesia recovery
breastfeedingbull Psychosocial issues
bull Fearbull Self-imageself-esteem
Post-Op Carebull Assess fundusbleeding vital signs DVTbull Antibiotics bull Pain Duramorph Breakthrough pain
meds Benadryl for itching Zofran for nausea
bull Clear liquids and advance as toleratedbull Assess for GI function Bowel sounds
Passing flatusbull Ambulation Pre-medicate teach splinting
with pillowbull Stool softener
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
multiparity excessive analgesia Afterpains wwwyoutubecomwatchv=EbItF_7KYCcampfeature=related
Fundal Assessment Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina Cervix returns to firm nongravid consistency
by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum Assessment turn pt to side in Simrsquos
position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments Constipation Give stool softeners as
ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis Superficial leg vein disease
ndash Ss tenderness in portion of vein local heat amp redness normal temperature or low-grade fever
ndash Tx local heat elevate limb bed rest analgesia elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation Engorgement day 3 or 4
ndash If breastfeeding Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
Postpartum Complications Postpartum Hemorrhage
ndash CAUSES Uterine atony lacerations retained placental fragments
Risk factorsndash uarr uterine distension multiples polyhydramnios
macrosomia fibroidsndash Trauma rapid or operative birthndash Placental problems previa accreta abruptio
retained placental fragmentsndash Atonic uterus prolonged pitocin magnesium
sulfate or labor uarr maternal age or parity uterine scar chorioamnionitis anemia prior history
ndash Inadequate blood coagulation fetal death or DIC
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole -Inadequate uterine relaxation between contractions lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveriesbull Forceps
bull Indications unable to push arrested descent need a quick delivery breech
bull Associated with maternalfetal birth trauma rectal sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
laborbull Elective
Placenta Factorsbull Placenta previabull Placental abruptionbull Umbilical cord prolapse
Fetal Factorsbull Breech transverse liebull Macrosomiabull Extreme low birth wtbull Fetal distressbull Fetal anomaliesbull Multiple gestation
Cesarean Birth (cont)bull Mortality
morbiditybull 4 x higher than
vaginal birth in US Most risk assoc with emergency c-section
bull Incisionbull Skin vs uterinebull Classical vs low
transverse
bull Maternal Complicationsbull Infectionbull Anesthesia reactionsbull DeepVeinThrombopheb
itisbull Bleedingbull Ureteralbladder injurybull Increase risk for
subsequent pregnancybull Placenta AcretaPrevia
Infertility
Cesarean Birthbull Pre-op CBC w platelets hold clotbull bicitraantacidbull monitor babybull Teaching pre amp post-op anesthesia recovery
breastfeedingbull Psychosocial issues
bull Fearbull Self-imageself-esteem
Post-Op Carebull Assess fundusbleeding vital signs DVTbull Antibiotics bull Pain Duramorph Breakthrough pain
meds Benadryl for itching Zofran for nausea
bull Clear liquids and advance as toleratedbull Assess for GI function Bowel sounds
Passing flatusbull Ambulation Pre-medicate teach splinting
with pillowbull Stool softener
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
multiparity excessive analgesia Afterpains wwwyoutubecomwatchv=EbItF_7KYCcampfeature=related
Fundal Assessment Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina Cervix returns to firm nongravid consistency
by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum Assessment turn pt to side in Simrsquos
position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments Constipation Give stool softeners as
ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis Superficial leg vein disease
ndash Ss tenderness in portion of vein local heat amp redness normal temperature or low-grade fever
ndash Tx local heat elevate limb bed rest analgesia elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation Engorgement day 3 or 4
ndash If breastfeeding Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
Postpartum Complications Postpartum Hemorrhage
ndash CAUSES Uterine atony lacerations retained placental fragments
Risk factorsndash uarr uterine distension multiples polyhydramnios
macrosomia fibroidsndash Trauma rapid or operative birthndash Placental problems previa accreta abruptio
retained placental fragmentsndash Atonic uterus prolonged pitocin magnesium
sulfate or labor uarr maternal age or parity uterine scar chorioamnionitis anemia prior history
ndash Inadequate blood coagulation fetal death or DIC
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
Operative Assisted Deliveriesbull Forceps
bull Indications unable to push arrested descent need a quick delivery breech
bull Associated with maternalfetal birth trauma rectal sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
laborbull Elective
Placenta Factorsbull Placenta previabull Placental abruptionbull Umbilical cord prolapse
Fetal Factorsbull Breech transverse liebull Macrosomiabull Extreme low birth wtbull Fetal distressbull Fetal anomaliesbull Multiple gestation
Cesarean Birth (cont)bull Mortality
morbiditybull 4 x higher than
vaginal birth in US Most risk assoc with emergency c-section
bull Incisionbull Skin vs uterinebull Classical vs low
transverse
bull Maternal Complicationsbull Infectionbull Anesthesia reactionsbull DeepVeinThrombopheb
itisbull Bleedingbull Ureteralbladder injurybull Increase risk for
subsequent pregnancybull Placenta AcretaPrevia
Infertility
Cesarean Birthbull Pre-op CBC w platelets hold clotbull bicitraantacidbull monitor babybull Teaching pre amp post-op anesthesia recovery
breastfeedingbull Psychosocial issues
bull Fearbull Self-imageself-esteem
Post-Op Carebull Assess fundusbleeding vital signs DVTbull Antibiotics bull Pain Duramorph Breakthrough pain
meds Benadryl for itching Zofran for nausea
bull Clear liquids and advance as toleratedbull Assess for GI function Bowel sounds
Passing flatusbull Ambulation Pre-medicate teach splinting
with pillowbull Stool softener
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
multiparity excessive analgesia Afterpains wwwyoutubecomwatchv=EbItF_7KYCcampfeature=related
Fundal Assessment Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina Cervix returns to firm nongravid consistency
by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum Assessment turn pt to side in Simrsquos
position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments Constipation Give stool softeners as
ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis Superficial leg vein disease
ndash Ss tenderness in portion of vein local heat amp redness normal temperature or low-grade fever
ndash Tx local heat elevate limb bed rest analgesia elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation Engorgement day 3 or 4
ndash If breastfeeding Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
Postpartum Complications Postpartum Hemorrhage
ndash CAUSES Uterine atony lacerations retained placental fragments
Risk factorsndash uarr uterine distension multiples polyhydramnios
macrosomia fibroidsndash Trauma rapid or operative birthndash Placental problems previa accreta abruptio
retained placental fragmentsndash Atonic uterus prolonged pitocin magnesium
sulfate or labor uarr maternal age or parity uterine scar chorioamnionitis anemia prior history
ndash Inadequate blood coagulation fetal death or DIC
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
laborbull Elective
Placenta Factorsbull Placenta previabull Placental abruptionbull Umbilical cord prolapse
Fetal Factorsbull Breech transverse liebull Macrosomiabull Extreme low birth wtbull Fetal distressbull Fetal anomaliesbull Multiple gestation
Cesarean Birth (cont)bull Mortality
morbiditybull 4 x higher than
vaginal birth in US Most risk assoc with emergency c-section
bull Incisionbull Skin vs uterinebull Classical vs low
transverse
bull Maternal Complicationsbull Infectionbull Anesthesia reactionsbull DeepVeinThrombopheb
itisbull Bleedingbull Ureteralbladder injurybull Increase risk for
subsequent pregnancybull Placenta AcretaPrevia
Infertility
Cesarean Birthbull Pre-op CBC w platelets hold clotbull bicitraantacidbull monitor babybull Teaching pre amp post-op anesthesia recovery
breastfeedingbull Psychosocial issues
bull Fearbull Self-imageself-esteem
Post-Op Carebull Assess fundusbleeding vital signs DVTbull Antibiotics bull Pain Duramorph Breakthrough pain
meds Benadryl for itching Zofran for nausea
bull Clear liquids and advance as toleratedbull Assess for GI function Bowel sounds
Passing flatusbull Ambulation Pre-medicate teach splinting
with pillowbull Stool softener
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
multiparity excessive analgesia Afterpains wwwyoutubecomwatchv=EbItF_7KYCcampfeature=related
Fundal Assessment Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina Cervix returns to firm nongravid consistency
by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum Assessment turn pt to side in Simrsquos
position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments Constipation Give stool softeners as
ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis Superficial leg vein disease
ndash Ss tenderness in portion of vein local heat amp redness normal temperature or low-grade fever
ndash Tx local heat elevate limb bed rest analgesia elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation Engorgement day 3 or 4
ndash If breastfeeding Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
Postpartum Complications Postpartum Hemorrhage
ndash CAUSES Uterine atony lacerations retained placental fragments
Risk factorsndash uarr uterine distension multiples polyhydramnios
macrosomia fibroidsndash Trauma rapid or operative birthndash Placental problems previa accreta abruptio
retained placental fragmentsndash Atonic uterus prolonged pitocin magnesium
sulfate or labor uarr maternal age or parity uterine scar chorioamnionitis anemia prior history
ndash Inadequate blood coagulation fetal death or DIC
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
Cesarean Birth (cont)bull Mortality
morbiditybull 4 x higher than
vaginal birth in US Most risk assoc with emergency c-section
bull Incisionbull Skin vs uterinebull Classical vs low
transverse
bull Maternal Complicationsbull Infectionbull Anesthesia reactionsbull DeepVeinThrombopheb
itisbull Bleedingbull Ureteralbladder injurybull Increase risk for
subsequent pregnancybull Placenta AcretaPrevia
Infertility
Cesarean Birthbull Pre-op CBC w platelets hold clotbull bicitraantacidbull monitor babybull Teaching pre amp post-op anesthesia recovery
breastfeedingbull Psychosocial issues
bull Fearbull Self-imageself-esteem
Post-Op Carebull Assess fundusbleeding vital signs DVTbull Antibiotics bull Pain Duramorph Breakthrough pain
meds Benadryl for itching Zofran for nausea
bull Clear liquids and advance as toleratedbull Assess for GI function Bowel sounds
Passing flatusbull Ambulation Pre-medicate teach splinting
with pillowbull Stool softener
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
multiparity excessive analgesia Afterpains wwwyoutubecomwatchv=EbItF_7KYCcampfeature=related
Fundal Assessment Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina Cervix returns to firm nongravid consistency
by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum Assessment turn pt to side in Simrsquos
position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments Constipation Give stool softeners as
ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis Superficial leg vein disease
ndash Ss tenderness in portion of vein local heat amp redness normal temperature or low-grade fever
ndash Tx local heat elevate limb bed rest analgesia elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation Engorgement day 3 or 4
ndash If breastfeeding Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
Postpartum Complications Postpartum Hemorrhage
ndash CAUSES Uterine atony lacerations retained placental fragments
Risk factorsndash uarr uterine distension multiples polyhydramnios
macrosomia fibroidsndash Trauma rapid or operative birthndash Placental problems previa accreta abruptio
retained placental fragmentsndash Atonic uterus prolonged pitocin magnesium
sulfate or labor uarr maternal age or parity uterine scar chorioamnionitis anemia prior history
ndash Inadequate blood coagulation fetal death or DIC
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
Cesarean Birthbull Pre-op CBC w platelets hold clotbull bicitraantacidbull monitor babybull Teaching pre amp post-op anesthesia recovery
breastfeedingbull Psychosocial issues
bull Fearbull Self-imageself-esteem
Post-Op Carebull Assess fundusbleeding vital signs DVTbull Antibiotics bull Pain Duramorph Breakthrough pain
meds Benadryl for itching Zofran for nausea
bull Clear liquids and advance as toleratedbull Assess for GI function Bowel sounds
Passing flatusbull Ambulation Pre-medicate teach splinting
with pillowbull Stool softener
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
multiparity excessive analgesia Afterpains wwwyoutubecomwatchv=EbItF_7KYCcampfeature=related
Fundal Assessment Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina Cervix returns to firm nongravid consistency
by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum Assessment turn pt to side in Simrsquos
position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments Constipation Give stool softeners as
ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis Superficial leg vein disease
ndash Ss tenderness in portion of vein local heat amp redness normal temperature or low-grade fever
ndash Tx local heat elevate limb bed rest analgesia elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation Engorgement day 3 or 4
ndash If breastfeeding Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
Postpartum Complications Postpartum Hemorrhage
ndash CAUSES Uterine atony lacerations retained placental fragments
Risk factorsndash uarr uterine distension multiples polyhydramnios
macrosomia fibroidsndash Trauma rapid or operative birthndash Placental problems previa accreta abruptio
retained placental fragmentsndash Atonic uterus prolonged pitocin magnesium
sulfate or labor uarr maternal age or parity uterine scar chorioamnionitis anemia prior history
ndash Inadequate blood coagulation fetal death or DIC
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
Post-Op Carebull Assess fundusbleeding vital signs DVTbull Antibiotics bull Pain Duramorph Breakthrough pain
meds Benadryl for itching Zofran for nausea
bull Clear liquids and advance as toleratedbull Assess for GI function Bowel sounds
Passing flatusbull Ambulation Pre-medicate teach splinting
with pillowbull Stool softener
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
multiparity excessive analgesia Afterpains wwwyoutubecomwatchv=EbItF_7KYCcampfeature=related
Fundal Assessment Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina Cervix returns to firm nongravid consistency
by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum Assessment turn pt to side in Simrsquos
position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments Constipation Give stool softeners as
ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis Superficial leg vein disease
ndash Ss tenderness in portion of vein local heat amp redness normal temperature or low-grade fever
ndash Tx local heat elevate limb bed rest analgesia elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation Engorgement day 3 or 4
ndash If breastfeeding Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
Postpartum Complications Postpartum Hemorrhage
ndash CAUSES Uterine atony lacerations retained placental fragments
Risk factorsndash uarr uterine distension multiples polyhydramnios
macrosomia fibroidsndash Trauma rapid or operative birthndash Placental problems previa accreta abruptio
retained placental fragmentsndash Atonic uterus prolonged pitocin magnesium
sulfate or labor uarr maternal age or parity uterine scar chorioamnionitis anemia prior history
ndash Inadequate blood coagulation fetal death or DIC
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
multiparity excessive analgesia Afterpains wwwyoutubecomwatchv=EbItF_7KYCcampfeature=related
Fundal Assessment Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina Cervix returns to firm nongravid consistency
by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum Assessment turn pt to side in Simrsquos
position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments Constipation Give stool softeners as
ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis Superficial leg vein disease
ndash Ss tenderness in portion of vein local heat amp redness normal temperature or low-grade fever
ndash Tx local heat elevate limb bed rest analgesia elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation Engorgement day 3 or 4
ndash If breastfeeding Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
Postpartum Complications Postpartum Hemorrhage
ndash CAUSES Uterine atony lacerations retained placental fragments
Risk factorsndash uarr uterine distension multiples polyhydramnios
macrosomia fibroidsndash Trauma rapid or operative birthndash Placental problems previa accreta abruptio
retained placental fragmentsndash Atonic uterus prolonged pitocin magnesium
sulfate or labor uarr maternal age or parity uterine scar chorioamnionitis anemia prior history
ndash Inadequate blood coagulation fetal death or DIC
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
multiparity excessive analgesia Afterpains wwwyoutubecomwatchv=EbItF_7KYCcampfeature=related
Fundal Assessment Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina Cervix returns to firm nongravid consistency
by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum Assessment turn pt to side in Simrsquos
position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments Constipation Give stool softeners as
ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis Superficial leg vein disease
ndash Ss tenderness in portion of vein local heat amp redness normal temperature or low-grade fever
ndash Tx local heat elevate limb bed rest analgesia elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation Engorgement day 3 or 4
ndash If breastfeeding Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
Postpartum Complications Postpartum Hemorrhage
ndash CAUSES Uterine atony lacerations retained placental fragments
Risk factorsndash uarr uterine distension multiples polyhydramnios
macrosomia fibroidsndash Trauma rapid or operative birthndash Placental problems previa accreta abruptio
retained placental fragmentsndash Atonic uterus prolonged pitocin magnesium
sulfate or labor uarr maternal age or parity uterine scar chorioamnionitis anemia prior history
ndash Inadequate blood coagulation fetal death or DIC
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
multiparity excessive analgesia Afterpains wwwyoutubecomwatchv=EbItF_7KYCcampfeature=related
Fundal Assessment Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina Cervix returns to firm nongravid consistency
by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum Assessment turn pt to side in Simrsquos
position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments Constipation Give stool softeners as
ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis Superficial leg vein disease
ndash Ss tenderness in portion of vein local heat amp redness normal temperature or low-grade fever
ndash Tx local heat elevate limb bed rest analgesia elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation Engorgement day 3 or 4
ndash If breastfeeding Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
Postpartum Complications Postpartum Hemorrhage
ndash CAUSES Uterine atony lacerations retained placental fragments
Risk factorsndash uarr uterine distension multiples polyhydramnios
macrosomia fibroidsndash Trauma rapid or operative birthndash Placental problems previa accreta abruptio
retained placental fragmentsndash Atonic uterus prolonged pitocin magnesium
sulfate or labor uarr maternal age or parity uterine scar chorioamnionitis anemia prior history
ndash Inadequate blood coagulation fetal death or DIC
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
multiparity excessive analgesia Afterpains wwwyoutubecomwatchv=EbItF_7KYCcampfeature=related
Fundal Assessment Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina Cervix returns to firm nongravid consistency
by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum Assessment turn pt to side in Simrsquos
position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments Constipation Give stool softeners as
ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis Superficial leg vein disease
ndash Ss tenderness in portion of vein local heat amp redness normal temperature or low-grade fever
ndash Tx local heat elevate limb bed rest analgesia elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation Engorgement day 3 or 4
ndash If breastfeeding Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
Postpartum Complications Postpartum Hemorrhage
ndash CAUSES Uterine atony lacerations retained placental fragments
Risk factorsndash uarr uterine distension multiples polyhydramnios
macrosomia fibroidsndash Trauma rapid or operative birthndash Placental problems previa accreta abruptio
retained placental fragmentsndash Atonic uterus prolonged pitocin magnesium
sulfate or labor uarr maternal age or parity uterine scar chorioamnionitis anemia prior history
ndash Inadequate blood coagulation fetal death or DIC
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
multiparity excessive analgesia Afterpains wwwyoutubecomwatchv=EbItF_7KYCcampfeature=related
Fundal Assessment Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina Cervix returns to firm nongravid consistency
by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum Assessment turn pt to side in Simrsquos
position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments Constipation Give stool softeners as
ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis Superficial leg vein disease
ndash Ss tenderness in portion of vein local heat amp redness normal temperature or low-grade fever
ndash Tx local heat elevate limb bed rest analgesia elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation Engorgement day 3 or 4
ndash If breastfeeding Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
Postpartum Complications Postpartum Hemorrhage
ndash CAUSES Uterine atony lacerations retained placental fragments
Risk factorsndash uarr uterine distension multiples polyhydramnios
macrosomia fibroidsndash Trauma rapid or operative birthndash Placental problems previa accreta abruptio
retained placental fragmentsndash Atonic uterus prolonged pitocin magnesium
sulfate or labor uarr maternal age or parity uterine scar chorioamnionitis anemia prior history
ndash Inadequate blood coagulation fetal death or DIC
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
multiparity excessive analgesia Afterpains wwwyoutubecomwatchv=EbItF_7KYCcampfeature=related
Fundal Assessment Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina Cervix returns to firm nongravid consistency
by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum Assessment turn pt to side in Simrsquos
position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments Constipation Give stool softeners as
ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis Superficial leg vein disease
ndash Ss tenderness in portion of vein local heat amp redness normal temperature or low-grade fever
ndash Tx local heat elevate limb bed rest analgesia elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation Engorgement day 3 or 4
ndash If breastfeeding Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
Postpartum Complications Postpartum Hemorrhage
ndash CAUSES Uterine atony lacerations retained placental fragments
Risk factorsndash uarr uterine distension multiples polyhydramnios
macrosomia fibroidsndash Trauma rapid or operative birthndash Placental problems previa accreta abruptio
retained placental fragmentsndash Atonic uterus prolonged pitocin magnesium
sulfate or labor uarr maternal age or parity uterine scar chorioamnionitis anemia prior history
ndash Inadequate blood coagulation fetal death or DIC
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
multiparity excessive analgesia Afterpains wwwyoutubecomwatchv=EbItF_7KYCcampfeature=related
Fundal Assessment Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina Cervix returns to firm nongravid consistency
by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum Assessment turn pt to side in Simrsquos
position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments Constipation Give stool softeners as
ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis Superficial leg vein disease
ndash Ss tenderness in portion of vein local heat amp redness normal temperature or low-grade fever
ndash Tx local heat elevate limb bed rest analgesia elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation Engorgement day 3 or 4
ndash If breastfeeding Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
Postpartum Complications Postpartum Hemorrhage
ndash CAUSES Uterine atony lacerations retained placental fragments
Risk factorsndash uarr uterine distension multiples polyhydramnios
macrosomia fibroidsndash Trauma rapid or operative birthndash Placental problems previa accreta abruptio
retained placental fragmentsndash Atonic uterus prolonged pitocin magnesium
sulfate or labor uarr maternal age or parity uterine scar chorioamnionitis anemia prior history
ndash Inadequate blood coagulation fetal death or DIC
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
Fundal Assessment Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina Cervix returns to firm nongravid consistency
by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum Assessment turn pt to side in Simrsquos
position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments Constipation Give stool softeners as
ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis Superficial leg vein disease
ndash Ss tenderness in portion of vein local heat amp redness normal temperature or low-grade fever
ndash Tx local heat elevate limb bed rest analgesia elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation Engorgement day 3 or 4
ndash If breastfeeding Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
Postpartum Complications Postpartum Hemorrhage
ndash CAUSES Uterine atony lacerations retained placental fragments
Risk factorsndash uarr uterine distension multiples polyhydramnios
macrosomia fibroidsndash Trauma rapid or operative birthndash Placental problems previa accreta abruptio
retained placental fragmentsndash Atonic uterus prolonged pitocin magnesium
sulfate or labor uarr maternal age or parity uterine scar chorioamnionitis anemia prior history
ndash Inadequate blood coagulation fetal death or DIC
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina Cervix returns to firm nongravid consistency
by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum Assessment turn pt to side in Simrsquos
position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments Constipation Give stool softeners as
ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis Superficial leg vein disease
ndash Ss tenderness in portion of vein local heat amp redness normal temperature or low-grade fever
ndash Tx local heat elevate limb bed rest analgesia elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation Engorgement day 3 or 4
ndash If breastfeeding Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
Postpartum Complications Postpartum Hemorrhage
ndash CAUSES Uterine atony lacerations retained placental fragments
Risk factorsndash uarr uterine distension multiples polyhydramnios
macrosomia fibroidsndash Trauma rapid or operative birthndash Placental problems previa accreta abruptio
retained placental fragmentsndash Atonic uterus prolonged pitocin magnesium
sulfate or labor uarr maternal age or parity uterine scar chorioamnionitis anemia prior history
ndash Inadequate blood coagulation fetal death or DIC
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina Cervix returns to firm nongravid consistency
by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum Assessment turn pt to side in Simrsquos
position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments Constipation Give stool softeners as
ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis Superficial leg vein disease
ndash Ss tenderness in portion of vein local heat amp redness normal temperature or low-grade fever
ndash Tx local heat elevate limb bed rest analgesia elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation Engorgement day 3 or 4
ndash If breastfeeding Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
Postpartum Complications Postpartum Hemorrhage
ndash CAUSES Uterine atony lacerations retained placental fragments
Risk factorsndash uarr uterine distension multiples polyhydramnios
macrosomia fibroidsndash Trauma rapid or operative birthndash Placental problems previa accreta abruptio
retained placental fragmentsndash Atonic uterus prolonged pitocin magnesium
sulfate or labor uarr maternal age or parity uterine scar chorioamnionitis anemia prior history
ndash Inadequate blood coagulation fetal death or DIC
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina Cervix returns to firm nongravid consistency
by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum Assessment turn pt to side in Simrsquos
position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments Constipation Give stool softeners as
ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis Superficial leg vein disease
ndash Ss tenderness in portion of vein local heat amp redness normal temperature or low-grade fever
ndash Tx local heat elevate limb bed rest analgesia elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation Engorgement day 3 or 4
ndash If breastfeeding Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
Postpartum Complications Postpartum Hemorrhage
ndash CAUSES Uterine atony lacerations retained placental fragments
Risk factorsndash uarr uterine distension multiples polyhydramnios
macrosomia fibroidsndash Trauma rapid or operative birthndash Placental problems previa accreta abruptio
retained placental fragmentsndash Atonic uterus prolonged pitocin magnesium
sulfate or labor uarr maternal age or parity uterine scar chorioamnionitis anemia prior history
ndash Inadequate blood coagulation fetal death or DIC
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
Cervix amp Vagina Cervix returns to firm nongravid consistency
by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum Assessment turn pt to side in Simrsquos
position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments Constipation Give stool softeners as
ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis Superficial leg vein disease
ndash Ss tenderness in portion of vein local heat amp redness normal temperature or low-grade fever
ndash Tx local heat elevate limb bed rest analgesia elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation Engorgement day 3 or 4
ndash If breastfeeding Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
Postpartum Complications Postpartum Hemorrhage
ndash CAUSES Uterine atony lacerations retained placental fragments
Risk factorsndash uarr uterine distension multiples polyhydramnios
macrosomia fibroidsndash Trauma rapid or operative birthndash Placental problems previa accreta abruptio
retained placental fragmentsndash Atonic uterus prolonged pitocin magnesium
sulfate or labor uarr maternal age or parity uterine scar chorioamnionitis anemia prior history
ndash Inadequate blood coagulation fetal death or DIC
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
Perineum Assessment turn pt to side in Simrsquos
position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments Constipation Give stool softeners as
ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis Superficial leg vein disease
ndash Ss tenderness in portion of vein local heat amp redness normal temperature or low-grade fever
ndash Tx local heat elevate limb bed rest analgesia elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation Engorgement day 3 or 4
ndash If breastfeeding Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
Postpartum Complications Postpartum Hemorrhage
ndash CAUSES Uterine atony lacerations retained placental fragments
Risk factorsndash uarr uterine distension multiples polyhydramnios
macrosomia fibroidsndash Trauma rapid or operative birthndash Placental problems previa accreta abruptio
retained placental fragmentsndash Atonic uterus prolonged pitocin magnesium
sulfate or labor uarr maternal age or parity uterine scar chorioamnionitis anemia prior history
ndash Inadequate blood coagulation fetal death or DIC
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
Episiotomy Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments Constipation Give stool softeners as
ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis Superficial leg vein disease
ndash Ss tenderness in portion of vein local heat amp redness normal temperature or low-grade fever
ndash Tx local heat elevate limb bed rest analgesia elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation Engorgement day 3 or 4
ndash If breastfeeding Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
Postpartum Complications Postpartum Hemorrhage
ndash CAUSES Uterine atony lacerations retained placental fragments
Risk factorsndash uarr uterine distension multiples polyhydramnios
macrosomia fibroidsndash Trauma rapid or operative birthndash Placental problems previa accreta abruptio
retained placental fragmentsndash Atonic uterus prolonged pitocin magnesium
sulfate or labor uarr maternal age or parity uterine scar chorioamnionitis anemia prior history
ndash Inadequate blood coagulation fetal death or DIC
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
Other Assessments Constipation Give stool softeners as
ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis Superficial leg vein disease
ndash Ss tenderness in portion of vein local heat amp redness normal temperature or low-grade fever
ndash Tx local heat elevate limb bed rest analgesia elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation Engorgement day 3 or 4
ndash If breastfeeding Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
Postpartum Complications Postpartum Hemorrhage
ndash CAUSES Uterine atony lacerations retained placental fragments
Risk factorsndash uarr uterine distension multiples polyhydramnios
macrosomia fibroidsndash Trauma rapid or operative birthndash Placental problems previa accreta abruptio
retained placental fragmentsndash Atonic uterus prolonged pitocin magnesium
sulfate or labor uarr maternal age or parity uterine scar chorioamnionitis anemia prior history
ndash Inadequate blood coagulation fetal death or DIC
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
Thrombophlebitis Superficial leg vein disease
ndash Ss tenderness in portion of vein local heat amp redness normal temperature or low-grade fever
ndash Tx local heat elevate limb bed rest analgesia elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation Engorgement day 3 or 4
ndash If breastfeeding Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
Postpartum Complications Postpartum Hemorrhage
ndash CAUSES Uterine atony lacerations retained placental fragments
Risk factorsndash uarr uterine distension multiples polyhydramnios
macrosomia fibroidsndash Trauma rapid or operative birthndash Placental problems previa accreta abruptio
retained placental fragmentsndash Atonic uterus prolonged pitocin magnesium
sulfate or labor uarr maternal age or parity uterine scar chorioamnionitis anemia prior history
ndash Inadequate blood coagulation fetal death or DIC
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation Engorgement day 3 or 4
ndash If breastfeeding Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
Postpartum Complications Postpartum Hemorrhage
ndash CAUSES Uterine atony lacerations retained placental fragments
Risk factorsndash uarr uterine distension multiples polyhydramnios
macrosomia fibroidsndash Trauma rapid or operative birthndash Placental problems previa accreta abruptio
retained placental fragmentsndash Atonic uterus prolonged pitocin magnesium
sulfate or labor uarr maternal age or parity uterine scar chorioamnionitis anemia prior history
ndash Inadequate blood coagulation fetal death or DIC
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation Engorgement day 3 or 4
ndash If breastfeeding Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
Postpartum Complications Postpartum Hemorrhage
ndash CAUSES Uterine atony lacerations retained placental fragments
Risk factorsndash uarr uterine distension multiples polyhydramnios
macrosomia fibroidsndash Trauma rapid or operative birthndash Placental problems previa accreta abruptio
retained placental fragmentsndash Atonic uterus prolonged pitocin magnesium
sulfate or labor uarr maternal age or parity uterine scar chorioamnionitis anemia prior history
ndash Inadequate blood coagulation fetal death or DIC
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation Engorgement day 3 or 4
ndash If breastfeeding Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
Postpartum Complications Postpartum Hemorrhage
ndash CAUSES Uterine atony lacerations retained placental fragments
Risk factorsndash uarr uterine distension multiples polyhydramnios
macrosomia fibroidsndash Trauma rapid or operative birthndash Placental problems previa accreta abruptio
retained placental fragmentsndash Atonic uterus prolonged pitocin magnesium
sulfate or labor uarr maternal age or parity uterine scar chorioamnionitis anemia prior history
ndash Inadequate blood coagulation fetal death or DIC
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
Lactation Engorgement day 3 or 4
ndash If breastfeeding Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
Postpartum Complications Postpartum Hemorrhage
ndash CAUSES Uterine atony lacerations retained placental fragments
Risk factorsndash uarr uterine distension multiples polyhydramnios
macrosomia fibroidsndash Trauma rapid or operative birthndash Placental problems previa accreta abruptio
retained placental fragmentsndash Atonic uterus prolonged pitocin magnesium
sulfate or labor uarr maternal age or parity uterine scar chorioamnionitis anemia prior history
ndash Inadequate blood coagulation fetal death or DIC
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
Discharge Instructions Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
Postpartum Complications Postpartum Hemorrhage
ndash CAUSES Uterine atony lacerations retained placental fragments
Risk factorsndash uarr uterine distension multiples polyhydramnios
macrosomia fibroidsndash Trauma rapid or operative birthndash Placental problems previa accreta abruptio
retained placental fragmentsndash Atonic uterus prolonged pitocin magnesium
sulfate or labor uarr maternal age or parity uterine scar chorioamnionitis anemia prior history
ndash Inadequate blood coagulation fetal death or DIC
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
Postpartum Complications Postpartum Hemorrhage
ndash CAUSES Uterine atony lacerations retained placental fragments
Risk factorsndash uarr uterine distension multiples polyhydramnios
macrosomia fibroidsndash Trauma rapid or operative birthndash Placental problems previa accreta abruptio
retained placental fragmentsndash Atonic uterus prolonged pitocin magnesium
sulfate or labor uarr maternal age or parity uterine scar chorioamnionitis anemia prior history
ndash Inadequate blood coagulation fetal death or DIC
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
Hemorrhage
Interventionsndash Fundal massage ensure
bladder emptying If uterus is firm but bleeding persists suspect laceration
ndash Administer oxtocics (pitocin methergine hemabate prostaglandins) blood replacement
ndash Frequent assessment of bleeding vital signs ndash MD Bimanual massage
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
Hemorrhage (cont) Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
Postpartum Infection Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
Postpartum Infection Endometritis infection of endometrium
ndash Associated with chorioamnionitis amp C-section
ndash SS foul-smelling bloody vaginal discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
Postpartum Infection Nursing Interventions amp Discharge Teaching
ndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)
Breastfeeding wwwyoutubecomwatchv=CIZ6rVzs4CEampfeature=Pl
ayListampp=BD065FA5F03CD81Aampindex=38 (Breastfeeding Basics)
wwwyoutubecomwatchv=RuvJZGFOHUampfeature=PlayListampp=1330DE183266B0BCampplaynext=1ampplaynext_from=PLampindex=3 (Whatrsquos the Big Deal)
wwwyoutubecomwatchv=Ox8ht-EVnQAampfeature=PlayListampp=1330DE183266B0BCampindex=8 (latch-on 1)
wwwyoutubecomwatchv=WOQzEN_dcPcampfeature=PlayListampp=1330DE183266B0BCampindex=9 (latch-on 2)