Perinatal Nursing

PERINATAL NURSING (Taken from Google Document)

1. acrocyanosis- A blue or purple mottled discoloration of the extremities, esp. the fingers, toes and/or nose. This physical finding is associated with many diseases and conditions, such as anorexia nervosa, autoimmune diseases, cold agglutinins, or Raynaud’s disease or phenomenon. Cyanosis of the extremities may be commonly observed in newborns and in others after exposure to cold temperatures, and in those patients with reduced cardiac output. In patients with suspected hypoxemia, it is an unreliable sign of diminished oxygenation.

2. Moro- or startle reflex- a reflex seen in infants in response to stimuli, such as that produced by suddenly striking the surface on which the infant rests. The infant responds by rapid abduction and extension of the arms followed by an embracing motion of the arms.

3. cephalhematoma- a mass composed of clotted blood, located between the periosteum and the skull of a newborn. It is confined between suture lines and usually is unilateral. The cause is rupture of periosteal bridging veins due to pressure and friction during labor and delivery. The blood reabsorbs gradually within a few weeks of birth.

4. caput succedaneum- diffuse edema of the fetal scalp that crosses the suture lines. Head compression against the cervix impedes venous return, forcing serum into the interstitial tissues. The swelling reabsorbs within 1 to 3 days.

5. ductus arteriosis- a channel of communication between the main pulmonary artery and the aorta of the fetus. 6. ductus venosus- the smaller, shorter, and posterior of two branches into which the umbilical vein divides after entering the abdomen of the fetus. It empties into the inferior vena cava.

7. fontanel-anterior and posterior-where located?-why?-shape?- an unossified membrane or soft spot lying between the cranial bones of the skull of a fetus or infant. Anterior- the diamond-shaped junction of the coronal, frontal, and sagittal sutures; it becomes ossified within 18 to 24 months. Posterior- the triangular fontanel at the junction of the sagittal and lambdoid sutures; ossified by the end of the first year.

8. foramen ovale- The opening between the two atria of the fetal heart. It usually closes shortly after birth as a result of hemodynamic changes related to respiration.

9. molding- shaping of the fetal head to adapt itself to the dimensions of the birth canal during its descent through the pelvis.

10. erythema toxicum- (papules, 24-28 hr.-newborn rash) a benign, self-limited rash marked by firm, yellow-white papules or pustules from 1 to 2 mm in size present in about 50% of full-term infants. The cause is unknown, and the lesions disappear without need for treatment.

11. chemical conjunctivitis- most common eye infection- of the conjunctiva usually caused by chemical burns. 12. vernix caseosa- a protective sebaceous deposit covering the fetus during intrauterine life, consisting of exfoliations of the outer skin layer, lanugo, and secretions of the sebaceous glands. It is most abundant in the creases and flexor surfaces. It is not necessary to remove this after the fetus is delivered.

13. lanugo- fine downy hairs that cover the body of the fetus, esp. when premature. The presence and amount of lanugo aids in estimating the gestational age of preterm infants. The fetus first exhibits lanugo between weeks 13 and 16. By gestational week 20, it covers the face and body. The amount of lanugo is greatest between weeks 28 and 30. As the third trimester progresses, lanugo disappears from the face, trunk, and extremities.

14. milia- white pinhead-size, keratin-filled cyst. In the newborn, milia occur on the face and, less frequently, on the trunk, and usually disappear without treatment within several weeks.

15. telangiectatic nevi or hemangioma- (stork bite) a benign tumor of dilated blood vessels. 16. Mongolian spots- bluish-black areas of pigmentation may appear over any part of the exterior surface of the body. Commonly noted whose ethnic origins are in the Mediterranean area, Latin America, Asia, or Africa

17. Apgar (know scoring)- a system for evaluating an infant’s physical condition at birth. The infant’s heart rate, respiration, muscle tone, response to stimuli, and color are rated at 1 min, and again at 5 min after birth. Each factor is scored 0,1, or 2; the maximum total score is 10. Interpretation of scores: 7 to 10, good to excellent; 4-6, fair; less than 4, poor condition. A low score at 1 min is a sign of perinatal asphyxia and the need for immediate assisted ventilation. Infants with scores below 7 at 5 min should be assessed again in 5 more min; scores less than 6 at any time may indicate need for resuscitation. In depressed infants, a more accurate determination of the degree of fetal hypoxia may be obtained by direct measures of umbilical cord oxygen, carbon dioxide partial pressure, and pH.

18. Silverman (respiratory function test)- 5 evaluations – what are they? – (handout) 1. Upper chest. 2. Lower chest. 3. Xiphoid retractions. 4. Nares dilation. 5. Expiratory grunt. Graded 0, 1, 2

19. pseudomenstruation- withdrawal bleeding after birth, a scant vaginal discharge that reflects the physiological response of some female infants to an exposure to high levels of maternal hormones in utero.

20. tonic neck reflex- (“fencing”) –with infant facing left side, arm and leg on that side extend; opposite arm and leg flex (turn head to right, and extremities assume opposite postures).

21. colostrum- high in?-breast fluid that may be secreted from the second trimester of pregnancy onward but that is most evident in the first 2 to 3 days after birth and before the onset of true lactation. This thin yellowish fluid contains a great number of proteins and calories in addition to immune globulins.

22. neonate- from birth through 28h day of life. 23. bilirubin – normal? Why higher in neonate?- normal 4000g (9 pounds) o Unexplained stillbirth o Miscarriage o Congenital anomalies

Hormonal influences during pregnancy •

•

1st trimester: Insulin sensitivity due to: o increased estrogen and progesterone o results in:  decreased glucose in mom  mom may become hypoglycemic 2nd trimester: Insulin breakdown due to: o Human placental lactogen (hPL) o Increased breakdown of insulin due to:  Placental insulinase o Overall effects:  Increased plasma glucose levels = hyperglycemia  Increased insulin requirements

Insulin needs •

Diabetogenic effect on pregnancy o Is usually a good thing o Increased insulin needs to be released to cover glucose in laboring moms

Effects on mom when she doesn’t have enough insulin • • • • • • • •

Difficult labor Increased risk of pregnancy induced hypertension Polyhydramnios: amniotic fluid > 2000 ml (remember, 1500 ml is the regular) Postpartum hemorrhage UTI Ketoacidosis ◊ death of mom and baby If mom has extra glucose circulating, it goes directly to the baby Remember, mom and baby share glucose, but not insulin.

Effect on baby (not enough insulin) • • • • •

Macrosomia: “large body” Insulin does not cross placenta, which results in: o Increased insulin production from baby o Acts as a growth hormone Hypoglycemia o When umbilical cord is cut, the glucose from mom stops. o The result is a newly born, very hypoglycemic baby. Difficult birth o Shoulder dystocia or other injury due to macrosomia (large baby) Congenital anomalies

• • •

Intrauterine growth retardation (IUGR) Lungs less mature Fetal death

Management of Gestational Diabetes

Detection and diagnosis •

Screen pregnant women at high risk for GDM for diabetes o 24-28 weeks  50gm oral glucose tolerance test (GTT)  Pre-gestational diabetes (HbA1c)

Goals for GDM •

• •

Maintain normal glucose levels o Fasting glucose levels 160/110 (x2) 4-6 hours apart o Weight gain—same as mild Preeclampsia o Proteinuria >4+ dipstick o Urine output < 30 ml/hr o Generalized edema, may also include pulmonary edema  Crackles heard in lungs o Cerebral (headache) or visual (blurred vision) changes o Liver involvement o Thrombocytopenia (decrease in number of platelets) with low platelet count (same thing?) o Cardiac involvement o Hyperreflexia >3+ o Development of HELLP syndrome  Hemolysis (destruction of RBC’s) H  Elevated liver enzymes EL  Low platelets LP o Fetus growth severely shunted

Care of patient with severe Preeclampsia/HELLP syndrome • • • • • •

Hospitalized until baby is delivered Bedrest on side Bed near nurse’s station with code cart nearby Quiet, calm environment Siderails up, padded Frequent assessments to include: o BP, P, R o Daily weight o Assess edema o Deep tendon reflexes o Assess for headache, visual disturbances, epigastric pain (liver is getting involved) o Insert foley o Strict I and O o Evaluate urine for protein o Monitor fetal well-being o Assess labs; platelets, liver enzymes

Medical management

•

•

Prevent seizures◊ MAGNESIUM SULFATE o Decreases neuromuscular irritability o Decreases CNS irritability (anticonvulsant effect) o Promotes maternal vasodilation, better tissue perfusion o Watch for magnesium toxicity  Loss of knee-jerk reflexes  Respirations 60  Retractions  Grunting  Cyanosis  Nasal flaring  Hypoxia ◊ lactic acid production  Increased CO2 ◊ acidosis  Hemoglobin unable to carry O2 molecule  X-ray’s show “white out” of the lungs  Increasing central cyanosis

  

Increased HR Hypothermia Decreased activity level

Medical management •

• •

Prevent preterm birth o Aggressive treatment of premature labor o Bethmethasone (steroid) to mom  Enhances fetal lung development  Needs to be given within 24 hours of birth Surfactant replacement therapy o Administer surfactant via E-T tube at birth for all preemies Must establish ventilation and administer oxygen o Ventilator via ET tube

Thermal regulation •

• • • • •

Poor thermal stability in preemie o Large surface area in comparison to body weight o Reduced muscle and fat deposits  Brown fat begins after 28 weeks o Poor glycogen and lipid stores o Limited ability to shiver o Usually less active Posture is flaccid ◊ increasing surface area exposed Increase in insensible fluid loss ◊ dehydration Respiratory distress◊ fosters more work of breathing Delivery rooms 62-68* F Cold stress results in: o Hypoxia o Metabolic acidosis o Hypoglycemia o Interventions for cold stress:  Isolette or warmer  Minimize drafts  Prewarm all surfaces  Bathing: keep covered; water warm  Knitted caps and booties  If oxygen is used, warm and moisturize it  Keep isolette covered—light is a stimulus

Nutritional Status •

Digestive system o Small stomach o Poor muscle tone – cardiac sphincter  Can cause vomiting o Gag and cough reflexes are poor  Aspiration is a problem o Decreased absorption of fat o Limited ability to convert glucose to glycogen o Lacks sucking until 32-34 weeks o Gavage feedings may be necessary until sucking reflex occurs o Give baby a soft preemie nipple to stimulate sucking as they are receiving gavage feedings.

Skin • • •

Decreased subcutaneous fat Reddened Translucent

Immature liver • • • •

Cannot conjugate bilirubin: Jaundice. o Treatment is phototherapy Cannot store or release glucose ◊ hypoglycemia Decrease in hemoglobin and production of blood ◊ anemia Does not make or store vitamin K ◊ hemorrhage

Immature kidneys • •

Increased Na excretion ◊ hyponatremia Decreased ability to concentrate urine ◊ dehydration

Infections •

Immature immune system and other reasons

Neuromuscular • • •

Poor muscle tone Weak reflexes Weak, feeble cry

Developmental considerations • • • • •

Encourage bonding with parents Encourage visiting with parents and siblings Kangaroo care o Skin-to-skin touch Twin co-bedding Positioning

Small for gestational age (SGA) •

Less that 10% on the newborn classification chart.

Causes: •

Due to intrauterine growth retardation (IUGR)

Two types: • •

Symetric o Infant looks normal but is very small o Usually problem happens during first trimester (infections) Asymmetric o Later in pregnancy o Long arms/legs; looks like a “skinny old man” o Usually weight 10%

Factors contributing to SGA: •

•

•

Maternal causes: o Poor nutrition (especially in last trimester) o Advanced diabetes  Vessels are constricted in mom; not enough blood/nutrients going to fetus. o PIH o Smoking and drug (cocaine) use. o Age over 35  Due to physiological changes in mom Placental causes: o Partial placental separation o Malfunction  Unable to obtain or transport nutrients for baby (Decreased blood flow) Fetal causes: o Intrauterine infection o Chromosomal abnormalities and malformations

Assessment findings for SGA (mostly asymmetrical) •

• • • • • • • • •

Skin o Loose and dry o Little fat o Little muscle mass Small body o Skull appears larger Sunken abdomen o Thin, dry umbilical cord Little scalp hair Wide scalp sutures Respiratory distress Hypoglycemic Tremors Weak cry Lethargic

Interventions for SGA: •

Similar to those of the preterm infant

Large for gestational age; LGA • •

Neonate whose birth weight is above the 90th percentile on the newborn classification chart. Subject to overproduction of growth hormone in utero. (Insulin, if mom was diabetic)

•

May be preterm, term, or post-term

Causes of LGA: • • • •

Mother with poorly controlled diabetes Multiparity Infant with transposition of the great vessels (unknown cause) Genetic predisposition

Problems associated with LGA: • • • • •

May require C-section Higher incidence of birth trauma with vaginal delivery o Fractured clavicle, brachial plexus palsies, depressed skull fractures, cephalhematomas Fetal distress during prolonged difficult second stage labor (respiratory distress) Hypoglycemia Polycythemia◊ look for hyperbilirubinemia

Physical findings in LGA infant • • • • • • •

Weight greater than 4000 grams (8lb, 14.5 oz) Caput succedaneum (goes over suture) o Edema on top of head where it is pushed against cervix during labor (fluid). Cephalhematoma (does not go over suture) o Blood collection due to rupturing during birth Facial nerve damage o Unsymmetrical face (mostly seen while crying) Infant at risk for pre and postnatal complications Hypoglycemia is a major problem (serum glucose 12) o Feeding difficulties

Interventions for the LGA infant: •

•

Monitor glucose levels o At birth o Every 2 hours for the first 8 hours o Every 4 hours for 24 hours or until stable Offer glucose, breast milk, or formula before 4 hours of age o Gavage if respirations >60 o Glucose infusion if necessary  Has to be done in the NICU

Maternal Infections

Beta-hemolytic, Group B Strept

• • • • • •

Major cause of infection in newborns Natural inhabitant of female genital tract Check culture results from mom prenatally. o Will check infant’s CBC if GBS is unknown In mother Treat: o Wash your hands to prevent epidemic in nursery o Ampicillin IV at 28 weeks and during delivery Pneumonia in infant ◊ 20% die within 24 hours Meningitis ◊ 2-4 weeks of age. 50% are brain damaged.

Maternal Infections- TORCHS • •

Group of maternal infectious diseases o Systemic, active diseases Can lead to serious complications in embryo, fetus, and neonate o T: Toxoplasmosis o O: Other, Hep. B, HIV o R: Rubella o C: CMV (Cytomegalovirus) o H: Herpes o S: syphilis

Toxoplasmosis • • •

Transmitted to fetus via mother’s contact with contaminated cat box filler Therapeutic abortion recommended if diagnosis is made before 20th week o These fetus’ often spontaneously abort Effects: Stillbirths, neonatal deaths, severe congenital anomalies, retinochoroiditis (inflammation of the retina and choroid), seizures, coma.

Rubella • • •

Greatest risk in the first trimester Effects: Congenital heart disease, IUGR, cataracts, mental retardation, hearing impairments, microcephaly, extensive fetal malformations. Treatment: Therapeutic abortion if in 1st trimester

CMV: Cytomegalovirus • • • • •

Member of the herpes virus group transmitted via placenta or cervix during delivery. Most frequent cause of viral infections in the fetus. o Brain, liver, and blood damage. CMV: Common cause of mental retardation Other effects: o Hearing defects o SGA infant Antiviral drugs cannot prevent CMV or treat the neonate.

Herpes Virus Type II • •

Fetus is exposed from: o Placenta during pregnancy, or genital tissues from delivery May be asymptomatic 2-12 days

Then develops jaundice, seizures, fever, vesicular lesions, stomatitis (inflammation of the mouth). Treatment: o C-section delivery protects the fetus from infection during active phases o Acyclovir 21 days to infant Healthcare workers with active lesions cannot care for babies. o

• •

Syphilis • •

•

Congenital syphilis diagnosed with serology tests at 3 and 6 months Symptoms: o Vesicular lesions on soles, palms; irritability o SGA, failure to thrive, rhinitis, red rash at mouth and anus, copper rash on face, soles, palms. Treatment: o Penicillin, isolation o Cover baby’s hands to prevent skin trauma from scratching.

Other: •

• •

Hepatitis B: o Babies are routinely vaccinated at birth o Babies with positive mothers are given immunoglobin to decrease infection possibility. HIV: o Babies born with HIV status Gonorrhea and Chlamydia o Eye infection/blindness. Treat with eye ointment erythromycin within one hour of birth.

Hemolytic disease of the newborn • •

Occurs when blood group of mother and infant are different Most common: o Rh factor o ABO incompatibility

Rh incompatibility • • • •

Isoimmunization or Rh sensitization 10-15% Caucasian couples 5% African American couples Rh- mom has Rh+ fetus: o If mom is Rh- and baby is Rh-, no danger o If mom is Rh+ and baby is Rh-, no danger o Only Rh+ offspring of an Rh- mother is at risk

Pathology of Rh factor: • • •

Formation of blood cells begins by 8th week of gestation In up to 40% of pregnancies, these cells pass through placenta into mother’s circulation When the fetus is Rh+ and the mom is Rh-, the mother forms antibodies against the fetal blood cells.

• •

• • • •

• •

Always ask… what is the baby’s blood type? Sensitization can occur during: o Pregnancy o Birth o Abortion/miscarriage o Amniocentesis Usually happens during the first pregnancy with Rh+ fetus; does not produce enough antibodies to cause harm to fetal blood cells. Problems occur with the next pregnancies as more antigens form Causes destruction of fetal blood cells. Fetus compensates for this destruction by producing large numbers of immature erythrocytes (RBC’s) to replace the destroyed ones. o Causes Erythroblastosis fetalis (immature new RBC cannot compensate or replace older, more mature RBC). Continued RBC destruction and anemia ◊ jaundice and marked fetal edema (hydrops fetalis) ◊ congestive heart failure. Breakdown of RBC’s releases bilirubin ◊ jaundice o Can lead to kernicterus (yellow staining on the brain) ◊ neurological damage.

Assessment and prevention of Rh Isoimmunization •

• • • •

• • • • •

All pregnant women are assessed for: o Blood group o Rh factor o Routine antibody screening o Note history of:  Previous miscarriage  Blood transfusions  Infants experiencing jaundice If client is Rh-, test father Rh- mother and Rh- father = Rh- fetus Indirect Coombs test (on mother): o To determine if Rh- mom has developed antibodies to Rh antigen Direct Coombs test (on baby’s blood) to identify maternal antibodies attached to fetal RBC’s. o If the direct Coombs test is positive, this is when problems occur. Watch baby closely for signs of jaundice. Rh immune globulin within 72 hours after birth prevents sensitization in Rh- woman who has had a fetomaternal transfusion of Rh+ fetal RBC’s. Suppresses antibody formation in mom Also given at 28 weeks gestation as prophylaxis o Rhogam is NOT long lasting 300 ug (1 vial) of Rh immune globulin usually enough (given IM) If large fetomaternal transfusion is suspected, a Kleihauer-Betke test is done (detects the amount of fetal blood in maternal circulation).

ABO incompatibility • • • • • • •

More common than Rh incompatibility Causes less severe problems Mom’s blood is O, fetus blood is A, B, or AB o Naturally occurring anti-A and anti-B antibodies transfer across placenta to fetus. Baby may show weak positive Coombs test result May result is hyperbilirubinemia that can be treated with phototherapy. Rarely does this incompatibility lead to the severe anemia of Rh incompatibility. First time infant will have the most issues that other children.

Postpartum Care

Goals for mom and family: • • • •

To To To To

understand changes taking place in mom’s body (vag/c-section) know how to care for infant know how to care for self know when to contact the healthcare system

Changes that occur during the postpartal period

Postpartal period: • • • •

First 6 weeks after birth Begins with the delivery of the placenta Ends when body systems return to the pre-pregnant stage Also called “Puerperium”

Reproductive systems •

•

•

Uterus: o Rapidly shrinks in size o Called involution of uterus o After the delivery, the uterus is the size of a grapefruit (2.4 lbs) o 1 week: 500 grams o 6 weeks: 50 grams o Uterus cannot typically be palpated after 10 days o Contractions after the baby is born causes the uterus to shrink o Muscle fibers shorten o Wall of uterus thickens and gets smaller o The uterus never returns to its prepregnant size o Uterus (fundus) decreases at a predictable rate  2 cm below umbilicus a few minutes after birth  1 cm above umbilicus at 12 hours  and then, descends one fingerbreath (1 cm) per day o No longer palpable by day 9 or 10 Subinvolution of the uterus: o This is a bad thing. o Uterus does not return to nonpregnant state. o Most common reasons:  Retained placental fragments  Infections Fundus should be midline. If not, it could be because mother has a full bladder. o Fundus should be firm, not boggy.  If its boggy, it could indicate hemorrhage

Uterine contractions • •

Begin immediately after the placenta is delivered The hormones that control the contractions are: o Oxytocin (pituitary gland; strengthens and coordinates the contractions)

• •

•

During the first 1-2 hour PP, uterine contractions may decrease o Muscles are tired! Exogenous Oxytocin given after the delivery of the placenta o Pitocin: IV or IM  Stimulates uterine smooth muscle contractions Breastfeeding is another strategy to increase contractions—releases oxytocin

Contractions and “afterpains” • •

Cramping with contractions o Does not usually occur in first time mothers: the more the body has been pregnant, the more the body has to work to shrink the stretched uterus. Usually occurs in: o Multigravida o Twins are large baby o Breastfeeding tends to increase afterpains o Last 2-3 days

Placental Site: • • • • •

Large and open wound Blood vessels pinched off; thrombi form, seal the site Eventually endometrial tissue forms over the raw area Scar tissues does not typically form Contractions help constrict blood vessels to clot where the placenta was

Lochia: Postchildbirth uterine discharge

Classifications of Lochia: •

•

•

Lochia o o o Lochia o o o o

Rubra: (1-3 days) Consists almost entirely of blood with small particles of deciduas and mucus. Small blood clots For the first 2 hours after birth, amount is very similar to heavy menstrual flow. Serosa: (4-10 days) Pink or reddish brown (old blood, leukocytes, tissue debris) Watery No clots No odor to earthy like menses

Lochia o o o

Alba (at 10 days) Colorless to white (or yellow) Can last 2-6 weeks in some women After 6 weeks, it could signal a sign of infection

Amount of Lochia • • •

Increases with breast feeding and BF (what in the hell is BF? If someone knows, please tell me) Tends to pool when in bed; may “gush” when first getting up in the a.m. If on pitocin, scant amounts

Estimating amount of lochia •

•

Amount of staining on pad: o Scant: 1-2” stain ◊ 10ml o Light (small) 4” stain ◊ 10-25 ml o Moderate: 6” stain ◊ 25-50 ml o Heavy: (large): saturated in one hour; >6” stain ◊ 50-80 ml Time factor important o Pad that saturates in one hour vs. 8 hours

Watch for… • • •

Bright red bleeding with firm uterus ◊ laceration Check underneath patient Saturation of a pad in less than one hour is an abnormally heavy flow

C-section Lochia • •

Lesser amount, but still goes through 3 stages The nurse may see later stages since the c-section patient is in the hospital longer

Cervix • • • •

Immediately after delivery: o Soft, edematous; partially open, can admit two fingers Within 24 hours, rapidly shortens, becomes firmer, thicker May look bruised with multiple small lacerations By 7 days, external os changes from a round opening to a slit-like opening; size of a pencil opening

Vagina • • • • • •

Greatly stretched Increased edema Small lacerations Very few rugae Estrogen (with ovulation) causes return to normal BF moms; ovulation is postponed; may experience vaginal dryness

Perineum • • • •

Muscles are torn and stretched, swollen and reddened Vulva is deep red, velvety appearance Lacerations, bruising around opening Hemorrhoids, commonly seen. Usually decrease after childbirth

Episiotomy

• • • • • •

Surgical cut, midline or mediolateral to the upper vaginal outlet Also to prevent laceration Prevents pressure on infant’s head Usually heals with little inflammatory reaction Remember—the more the degree (ex. 3rd degree), the larger/more advanced the cut. An alternative to an episiotomy is the massage of the vaginal opening (sounds pretty kinky to me!)

Perineal lacerations • •

Occur when the head is being born Classification: o 1st degree: perineal skin, no muscle involvement o 2nd degree: laceration extends through muscles of perineal body o 3rd degree: continues through anal sphincter muscle o 4th degree: through anal sphincter and into rectum

Hematoma •

May be present o Severe pain and rectal pressure o Can cause tissue necrosis

OUCH! • •

All of these conditions cause discomfort Relief of perineal pain is a nursing priority. Control pain!

Pelvic Muscle Support • • •

Pelvic floor muscles may require 6 months to regain tone Can lead to future problems Teach Kegel exercises

Endocrine system •

• •

Human placental lactogen (hPL), estrogen, cortisol, and insulinase gone ◊ reverses diabetogenic effect. o Moms with type 1 diabetes require less insulin; their body is more sensitive to insulin. Decreased estrogen aids in the diuresis of fluids Decreased progesterone levels

Pituitary hormone and ovarian function—Prolactin •

•

In lactating women: o Levels remain elevated o Suppresses ovulation for about 6 months o May have menses even if not ovulating Non-lactating women: o Prolactin levels decrease; reach pre-pregnant state in 3-4 weeks

o o

Ovulation at 27 days to 10 weeks 70% resume menses by 12 weeks

Prolactin and breastfeeding •

•

Non-lactating women: o May still secrete colostrum for 2-3 days o Engorgement of breast tissue occurs on 3rd day, lasts 24-36 hours, usually resolves on own o Should wear tight bra to compress milk ducts; cold applications to reduce swelling. Lactating women: o High level of prolactin initiates milk production within 2-3 days o Continues to be produced by contact with nursing baby

Other hormones released •

Oxytocin o Produced by hypothalamus, stored in posterior pituitary o Increases tone and mobility of uterine muscles o Breast response:  Oxytocin stimulates release of milk into lactiferous ducts; increases flow, NOT VOLUME, called “let-down” relex

Cardiovascular system • •

•

•

•

Normal blood loss in delivery in a single infant is: o Vag: 500 ml o C/S: 1000 ml Cardiac output: o Transient increase in blood volume after baby is born  Increase in blood volume increases BP and lowers Pulse  Bradycardia: 50-70 BPM. This is very normal due to all of the shifting of blood o Lasts about 48 hours or longer o Assess for LOC; dizziness, HA, confusion could indicate brain hypoxia Blood volume o Decreases due to:  Diuresis ◊ urine output is 3000 ml the first few days  Diaphoresis ◊ night sweats Blood clotting o During pregnancy increased fibrogen o Remains elevated until baby is born o Put mother’s at risk for DVT Blood values: o Greater loss of plasma than blood cells:  Increased hemoglobin  Increased hematocrit o WBC during first 10-12 days is 20-25,000. Could mask infection

Urinary system… 2 BIG problems •

Urinary retention o Much pressure on bladder and urethra during vaginal delivery o Decreased bladder tone o Edema of urethra o Decreased sensation to void o If epidural or spinal, feels no sensation until effects wear off

•

• •

Bladder distention o Due to postpartal diuresis ◊ within 12 hours o Should try to void within 1-2 hours o Bladder distention can lead to a very sad, boggy uterus. Lactosuria (presence of lactose/milk sugar) may be seen in nursing moms Slight proteinuria for 1-2 days

Gastrointestinal system • •

Appetite—usually very hungry Constipation o Decreased muscle tone in intestines o Muscles used for defecation stretched o May be delayed until 2-3 days PP o Fear of pain from episiotomy and hemorrhoids

Musculoskeletal system • •

Muscles and joints o Fatigue first 2 days PP o Ligaments and cartilage return to normal Abdomen: first two weeks are relaxed o Soft and flabby; takes about 6 weeks to regain tone o Striae fade to silver-white, but never completely disappear o Diastasis of the recti muscle (separation due to reduced muscle tone)

Skin • •

Mask of pregnancy, linea nigra usually disappear Striae do not disappear

Weight • • •

12-13 pounds lost at delivery 5-8 pounds following week from perspiration and diuresis) 19-22 pounds is the average weight loss

Major causes of maternal death in the postpartum period are infection and hemorrhage.

Assessment during the postpartal period • • •

•

4th stage—1 hour after placenta is delivered until stable o focus on preventing hemorrhage, rest; begin bonding with baby Postpartum period—4th stage to discharge o Prevent hemorrhage and infection; lactation; bonding; supervised care of baby; psychological stages, and teaching Vital signs: o Important to monitor VS of PP patient  Vitals q15m x 1 hour, the q30m x 1 hour; q1h x 1 hour, q4h x 24 Temperature

o o

o

•

•

May be up first 24 hours if exhausted or dehydrated  Up to 100.4*F 4th stage:  taken in recovery room once  should be normal or below due to hypothermia in L & D PP period q4h  Temp of 100.4 or above on any two (after first 24 hours) of 1st ten PP days = febrile. Assess for infection.  Lactating women will have a temp on 3rd or 4th day PP  Only lasts 12 hours  Teach to call M.D. if temp is over 100 at home

Pulse o o o Blood o

Transient Bradycardia of 50-70 BPM Tachycardia needs further assessment Pulse returns to normal within 1 week pressure 4th stage: slightly elevated from exhaustion, excitement  a drop means hemorrhage  check baseline from M.D.’s office o Postpartum  Should remain consistent with prelabor  An increase of 30 mmHg systolic or 15 mmHg diastolic or both could indicate PIH o Orthostatic hypotension when getting up  Patient will appear dizzy, pale, or may faint o C-section  Could be decreased due to anesthesia & greater blood loss

Breasts •

• • •

•

Assess for (palpate): o Softness o Firmness o Filling, colostrum o Engorged o Cracks, fissures o Redness Clean, well fitting bra on at all times Very little change for 3-4 days; colostrum only Engorgement: o Acute discomfort for 24 hours o Empty breasts q2h—nurse/mechanical o May need to release milk before feeding o Ice packs or heat o May experience fever for 8-12 hours when engorged Cracked/Bleeding nipples: o Analgesics 30-60 minutes before nursing o Use least sore breast first,  Plastic shells rarely used (some hospitals require consent form)  NO plastic breast pads o Feed no longer than 5-15 minutes o Wash with water only; then air-dry o Lanolin, tea bags, vary the position o At discharge; teach breast self-exam

GI/Abdomen • •

Listen for bowel sounds (especially C/S moms) For diastasis recti o Gradual exercise can resume immediately

•

C-section o Not as moveable due to dressings and staples; painful

Fundal check • • •

•

•

Empty bladder to avoid displacement Observe perineum while measuring fundus for clots and blood flow (Lochia, baby) If the fundus is soft and boggy, need to: o Check bladder o Check lochia amount, odor, quality  Massage to expel clots and tissue o Put baby to breast (stimulates contractions) o Check with M.D. immediately. Medications for the fundus crap: o Methergine po- causes tonic contractions (not very painful) o Pitocin IV- causes clonic contractions (painful) o BP must be lower than 140/90 to administer  Do not give IV and po simultaneously C-section: o Give analgesic before touching o Use only fingertips o Stays firm due to the pitocin in the IV

Education at discharge • • • • •

Teach how to find fundus lying flat on bed Teach how to massage Teach progression of involution and when to call M.D. Contraception, ovulation Increase in activity increases bleeding

Afterpains • •

Uterus contracting with involution (pitocin in IV or oral methergine) o Do not do fundal check; give analgesics and come back later Interventions: o Empty bladder o Lie prone o Leg lifts: contracts abdominal muscles; stimulates circulation o Analgesics 30-60 minutes before breastfeeding

Perineal Pain and assessment • • •

• •

Turn on side and lift buttocks, use pen light to see, wear gloves (duh) Episiotomy mediolateral most uncomfortable Check for edema and ecchymosis—REEDA o R: redness o E: edema o E: ecchymosis (bruising) o D: Discharge/drainage o A: approximation Perineal Varicosities = discomfort Hemorrhoids

Nursing interventions for perineal pain: •

•

•

Prevent infection o Handwashing is #1 o Change pads from front to back, do not touch inside o Peri care after each elimination—wipe with tissue front to back Provide comfort o Analgesia q4h if ordered  No aspirin! o Cold pack or ice in glove first 24 hours  On 20 minutes, off 20 minutes o After 24 hours; heat to increase blood flow o Sitz bath, spray, cream, witch hazel pads (tucks) o Teach Kegel exercises (handout) Teach how to sit: o Uncushioned chair or firm cushion, pillow on chair (no inflated rings) o Approach directly and flat o Perineum and buttocks contracted o Sit upright in back of chair

And more teaching… • • •

Teach peri care with peri bottle Inspect carefully; may use mirror at home Teach signs of complications and infections o REEDA o Temp over 100 o Increased pain o Pressure or fullness in vagina

Perineal care after C-section • • •

Perineum normal unless labored for a long period of time Hemorrhoids are still a reality Still needs peri care; will have lochia

Lochia • • • • • • • •

Assess color and amount Teach proper peri care 4th stage—use bedpan and peri bottle DO NOT touch inside of the pads Careful handwashing! Wipe front to back x 1 and discard, repeat until dry Teach stages of lochia DO NOT insert things into vagina

Lochia teaching at discharge •

• •

Teach for signs of deviations from normal and when to call M.D. o Foul odor with or without fever o Clots or tissue in lochia—distinguish between the two o Fever over 100 No tampons No sex while lochia persists

• •

Do not douche while lochia persists Prone position helps uterine descent and cramping

Lower extremities • • •

Assess for DVT Early ambulation Leg exercises in bed

Constipation • • • • • • •

Early ambulation Regular high fiber diet, liquids; 8-10 glasses qd Exercise muscles (Check with M.D.) Stool softeners, supp., enema Sitz baths Peri products to lessen pain Should BM within 3 days

Urinary Elimination •

Void within 6-8 hours (100-300 ml) to prevent: o Assess frequently for distention o Often, must catheterize

Nutrition • • • •

•

•

• •

Hungry and thirsty after delivery Dehydrated if no IV Regular high fiber diet for all moms except C-section May eat or drink except for (C-sectioned moms in particular): o N/V or general anesthesia o Flat in bed due to epidural o Sedated, drowsy, unconscious o Diabetic, cardiac, toxemic o Any special diet ordered by M.D. The main dietary concern immediately after delivery—increase fluids to replace fluids, electrolytes, blood volume from: o Diaphoresis o Exertion o Fluid loss during delivery o Fluids to help with voiding o Maintain normal temp o Maintain adequate nutrition o Take slowly to decrease nausea Intermediate care: o Encourage to eat adequate diet and fluids o 2000-2200 cal non-lactating o 2500-2700 cal lactating (500 more calories) C-section: o Post-op care, NPO, ice chips, clear liquids, soft diet o Progressive post-op diet Suppliments: o Prenatal vitamins until gone  Check Hbg and Hct

Sleep and rest: •

• •

4th stage: o exhausted from birth experience and frequent nursing checks o provide privacy for mom, dad, and baby o Encourage to sleep! PP to discharge: o After 1st 24 hours; ½ of time should be spent resting o Group your nursing activities Discharge: o Teach mom to sleep when baby sleep  Sleep deprivation leads to PPD o Assess for plan for help at home o Alteration in lifestyle disrupts sleep habits o May need to limit visitors and well-meaning friends

Comfort/PP Chill: • • • •

Occurs in 4th stage Due to sudden release of pressure on pelvic nerves Fetus to mother transfusion during placental separation Keep warm- blankets, warm liquids

Discharge teaching: • • • •

Teach all aspects of self-care Stress importance of keeping follow-up appointments Contraception When to call M.D. o Temp over 100 o Pain: perineum, breast, abdomen, calf or leg o Persistent or reversal of lochia, clots, odor, tissue o Saturating more than one pad per hour o Depression lasting two weeks or longer o Uterus not descending o C-section- open, draining, or odor of incision o Burning on urination

Postpartum Complications

Postpartum hemorrhage • • •

•

Major cause of maternal death Definition: o Blood loss after delivery >500 to 1000 ml/24 hours Classification: o Mild = 750-1250 ml o Moderate = 1250-1750 ml o Severe = 2500 ml Early o Within the first 24 hours

•

Late o

Anytime after first 24 hours through 6 weeks

Conditions that increase risk for PP hemorrhage •

• • • •

Over distension of the uterus o Multiple births (triplets, etc) o Hydroamnios o Macrosomia Trauma r/t forceps, uterine manipulation Prolonged labor- tilted uterus Uterine infection Trauma removing placenta

Causes of Postpartum hemorrhage •

Uterine Atony: Uterus without tone o 90% of cases o uterine muscle unable to contract around blood vessels at placental site o Causes:  Deep anesthesia  >30 years old  prolonged use of magnesium sulfate  previous uterine surgery  mom exhausted o Symptoms:  May have 2” blood clots  Blood may “gush” or come out slowly  Is usually venous blood o Therapeutic interventions  Massage uterus, then,  Give oxytocin drugs (pitocin or methergine po), then,  Bimanual compression (BY DOCTOR), then,  Administer prostaglandins (causes uterine contractions) intramyometrium or IM, then,  Hysterectomy or surgical repair (last resort) o Nursing interventions:  Blood transfusion  Fundal massage  Have patient void q4h or  Catheterize if too much blood lost  If SOB, give oxygen at 4L/NC  Frequent vital signs

•

Lacerations (large) o Cervical, vaginal, perineal o Causes by:  Forceps  Large baby o Symptoms- cervical  If uterine artery; bright red blood gushes out  Fundus is firm  Occurs at delivery, can be sutured o Symptoms- vaginal  Packing in place due to oozing of blood after repair  Remove packing in 24-48 hours (risk of infection increases)  Catheter in place o Symptoms- perineal

o

 Different degrees Nursing interventions for perineal lacerations:  3rd and 4th degree perineal lacerations- fecal incontinence  promote soft stools  roughage  stool softeners  fluid  activity  NO enemas or suppositories

•

Retained placenta o Fragments of placenta remained in uterus o Retained placental fragments cause decreased contractions o Some causes:  Massage prior to separation  Pulling on cord  Placenta “accrete”  Placenta actually grows into uterus  Cells of placenta (trophoblast) penetrate myometrium  Difficult for placenta to detach o Symptoms:  Large fragments  Patient bleeds immediately at delivery  Uterus is boggy  Small fragments  Occurs at 6th – 10th day PP  Can cause subinvolution o Interventions:  Remove fragments (D & C)  Massage  Manual exploration  Observe placenta after birth

•

Disseminated Intravascular Coagulation (DIC) o Deficiency of clotting ability o Caused by injury to blood vessel o Oozing of blood from IV site, other orifices o Very critical situation

•

Perineal Hematoma o Collection of blood in subcutaneous layer of tissue in perineum o Symptoms:  Bleeding is concealed; area of purplish discoloration/swelling on perineum  Fundus firm  Pain or pressure in perineum and rectum  Unable to void  May have signs of shock with firm uterus and no vaginal bleeding o Interventions:  Ice  Antibiotics  May need to do incision and evacuation, then suture

General Assessment Findings: • • •

Baseline H/H and history Condition of fundus o Boggy indicates atony o Firm fundus rules out atony, but bleeding could come from cervical laceration Look for symptoms of shock: o Pulse- rapid, thready o Pallor, chills o Air hunger, rapid respirations o Falling BP o Restless o Disturbed vision and hearing o Confusion, combative

General Nursing interventions • • • • • • • •

Identify patients at risk for conditions Monitor fundus frequently if bleeding occurs; when stable, every 15 minutes for 1-2 hours, then at usual intervals Monitor BP and pulse frequently Monitor character and amount of bleeding Administer medications, IV fluids as ordered Measure I & O Keep patient warm Monitor for signs of clotting defects with major loss (DIC) ◊ increased bleeding

Postpartum infection • • • •

• •

•

Infection of the reproductive tract associated with giving birth Usually occurs within 10 days of birth Another leading cause of maternal death Predisposing factors: o Prolonged rupture of membranes (>24 hours) o C-section o Trauma during birth process o Maternal anemia o Retained placental fragments Infection may be localized or systemic o Local = can spread to peritoneum (peritonitis) or circulatory (septic). o Fatal to woman already stressed with childbirth Assessment findings: o Temp of 100.4 for more than 2 consecutive days, excluding the first 24 hours. o Abdominal, perineal, or pelvic pain o Foul-smelling vaginal discharge o Burning sensation with urination o Chills, malaise o Rapid pulse and respirations o Elevated WBC, positive culture and sensitivity  Remember, 20-25,000 is normal after delivery—MASKING infection. Nursing interventions o Force fluids; may need more than 3L/day o Administer antibiotics and other meds as ordered o Treat symptoms as they arise o Encourage high calorie, high protein diet o Position patient in a semi-Fowlers to promote drainage and prevent reflux higher into reproductive tract

Urinary tract infection • •

•

May be caused postpartally by bacteria, coupled with bladder trauma during delivery, or break in technique during catherization. Assessment findings: o Pain in suprapubic area or at the lower costovertebral (between rib and vertebra) o Fever o Burning, urgency, frequency on urination o Increased WBC and hematuria o Urine culture positive for causative organism Nursing interventions o Check status of bladder frequently in PP patient o Encourage patient to void o Force fluids; may require 3L/day o Catheterize patient if ordered, using sterile technique o Administer meds as ordered o Continue to monitor labs

Perineal infection • •

•

Infection at site of episiotomy Assessment: o Skin changes o Edema o Redness o Pain exudate Management: o Monitor site o Promote drainage o Provide clean environment o Include wash with peri bottle, sitz bath, exposure to air o Teach good personal hygiene

Endometritis • •

•

Infection of endometrium involving superficial mucosal layer Signs: o Fundus does not descend o Fever and chills o Persistent foul lochia o Cramps Management: o IV therapy

Peritonitis • •

•

Inflammation of the perioneum o Thin membranous tissue that extends from the pelvic cavity and is continuous with abdominal cavity Assessment: o Elevated temperature o Shaking and chills o N/V o Oliguria o Abdominal distension Management: o Treatment focuses on maintaining adequate circulation and intravascular volumes o Antibiotic therapy

Thrombophlebitis • •

•

•

Seen in veins of legs and pelvis Causes: o Injury o Infection o Normal increase in circulating clotting factors in pregnant and newly delivered woman Assessment findings o Pain/discomfort in area of thrombus o If in leg:  Pain  Edema  Redness over affected area o Fever and chills o Peripheral pulses may be decreased. o Positive Homan’s sign o If in deep vein, leg may be cool and pale Nursing interventions: o Maintain bedrest with leg elevated on pillow. Do not raise knee gatch on bed. o Apply moist heat as ordered o Administer analgesics as ordered o Anticoagulant therapy (usually heparin or lovenox)  Observe for bleeding o Observe for signs of pulmonary embolism  SOB  Dyspnea

Psychological changes in the postpartal period

Postpartal period: • •

Time of change and adjustment to new role Reva Rubin, a nurse and pioneer in the field of maternal behavior

Process of becoming acquainted: •

• •

•

Bonding: o Initial attraction felt by parents toward their infant o Enhanced when able to touch and interact during the first 30-60 minutes after birth (touch and feel!). Attachment: o Process by which an enduring bond to an infant is developed over time o Different than bonding, more intense Mutual regulation: o A cueing system… each one sends out signals that can be read by the other.  Both the infant and the mothers needs are met o Crying, cooing, smiling “signaling behaviors”  Rooting, sucking, grasping; initiates and maintains contact with parents. Brings parents near. o Baby makes his needs known; a process that continues throughout childhood. Reciprocity: o Reciprocal- interaction style  Pleasure and delight in each other develops  Mutual development of love and growth



Entrainment: appears to listen to voice and follow face; baby’s movements synchronized with rhythm of parent’s speech

Maternal role attainment •

Process in which mother achieves confidence in her ability to care for infant

Phases of maternal role attainment: • •

• • • • •

Maternal touch: Changes as mom get to know infant o Enface position: eye contact Fingertip exploration: o Discovery process o Attachment is started o May take minutes or hours Palmar touch: entire hand Enfolding: baby in arms, pressing him/her to body Identification: ID’s baby as her own; clarifies feelings—what he looks like and what he can do. Relating: Characteristics of baby related to familiar person (nose like grandpa’s) Interpreting: Gives meaning to baby’s actions—he’s going to be a big eater like Uncle Bob.

Process of Maternal Adaptation •

•

•

•

Reva Rubin (1960’s) identified phases a mother goes through to: o Gain back energy lost during labor o Attain comfort in role of mother o Involves 3 phases:  Taking in  Taking hold  Letting go Taking in: o Passive-dependent stage (after delivery)  Time of reflection  Is passive  Wants others to meet her needs o Needs food, rest, in pain, very tired o Not a good phase for teaching Taking hold: o Dependent-independent stage (2nd day) o May be insecure, but want to be independent o Begins to initiate action o This is the best time for teaching o Although independent, still insecure about role as a mother o Needs praise and encouragement Letting go: o Interdependent stage (occurs at home) o Redefines her new role. Accepts:  Physical separation of baby  That she is no longer childless  Dependency of the child o Suffers role strain:  How to handle work and home  Torn between the two o Needs anticipatory guidance by the nurse:  Help at home  Babysitter  Time alone with companion

A word about fathers: • •

Mom’s preoccupation with baby can lead to jealousy o Encourage parents to talk freely and listen o Father may center attention on baby and ignore mom Father may need to be reassured about his role in the family o Dad needs to spend time alone with infant too

Postpartum blues: • • • • • • •

•

Adjustment disorder to a life event 50-75% of moms experience it; cries for no reason Patients go home so early, nurses don’t see it often. Expect to see 3-5 days postpartum Teach signs and symptoms Severity and symptoms vary with each individual Incidences seem to be decreasing. o Better OB care o Better preparation for new role—Lamaze, etc. o Allowing verbalization of feelings May be called the “Baby Blues”.

Symptoms of postpartum/baby blues: • • • • • • • • •

Loss of energy and appetite Crying for no reason Anxiety and fear; feel overwhelmed Insomnia Concerned about her body Reads into what others say, especially husband Directs anger toward husband Irritable Self-absorbed

Why does Postpartum/baby blues occur? • • • • • • • • • • • • • • •

Stress of labor and birth Hormonal changes General physical adjustments to non-pregnant state Sex of child Dealing with reality of new baby Attention is shifted away from pregnant mom now to baby She may feel husband is placing her 2nd to baby Immaturity Family, social, economic problems No help at home Mother may verbalize: o Sensation of feeling unprotected o Feeling of emptiness; compares to amputation Symptoms usually last 48 hours Give guidance before going home Need support; get help with baby & housework if needed, so mom can sleep Describe behaviors in charting

Postpartum depression- PPD • • • • • • • • • • • • • • •

Usually occur by 4th week PP, near menses, or at weaning o May occur up to one year PP In a fog Increase in irritability and anxiousness Crying Insomnia Somatic complaints Seclusiveness Excessive sleeping (while holding baby, etc.) Avoid baby Apathy toward husband Persists longer than 10 days Deepens Interferes with ADL’s Need professional consult Apparent within 3 months

Nursing responsibilities in PPD: • • •

Recognize symptoms Report to doctor Frequently happens within first 6 weeks at home

Most likely candidates in PPD: • • •

• • • • •

Mother with previous history of mental illness/instability Complicated pregnancy Stressful life situations o Abuse o More than 3 children o Single o Poverty o Drug dependence Feeling incompetent Cultural differences, etc. Poor mother/daughter relationship leading to rejection of reproductive role Lack of early support, attention, dependable relationship with either parent Own parent’s not available; negative or preoccupied

Nursing Implications of psychological factors: •

• •

• •

Prime importance: strengthen maternal-child relationship o Encourage physical contact between mother and baby immediately after birth o Allow active participation in caring for child as soon as possible Assess factors influencing psychological adjustment Promote caring and supportive atmosphere so mother can freely express feelings and needs. o Allow mom to set own pace as to assuming responsibility of self-care and care of child. Encourage fathers to actively participate in care of infant Encourage both parents to discuss with each other and nurse their reactions to parenthood and feeling about assuming new role

• •

Council parents about possibility of postpartal blues occurring after discharge from the hospital If symptoms persist or get worse: o Contact doctor o Medication or counseling may be needed o Support groups are available o Mental health centers o Parenting groups o National “DAD” hotline o May need hospitalization if threatens suicide or harm to baby

Preemies, children with deformities/disabilities, stillborn children: •

•

•

Anomalies o Difficult situation o Allow parents to talk o Allow parents to grieve o Say things like:  “This just isn’t fair”  “This is a lousy thing to have happened”  “You must be feeling very frightened” Premature baby: o Be sure parents see and touch baby as soon as possible o Take parents to NICU o ALWAYS keep them informed of what is happening o If transferred away from hospitalized mom:  Pictures are important  Phone calls 24 hrs/day to NICU nursery at Children’s o They’re often not ready for baby at home  Nursery, clothes may be needed  Thrown off schedule with work, etc.  Time, energy, money—long term effects o Explain to siblings o Do not forget the father in all of this o Don’t try to stop grief—allow her to express feelings o Encourage support groups  Preemies often have health problems; parents need support. Stillborn child o Parents need to see, touch, wash, and dress baby o Get footprints, pictures, lock of hair, ID band, name the child and use the name often. o If they don’t see their baby; the parents often never face reality and stuck in the grieving process. o Again, encourage to hold, rock, and cuddle their baby. o Allow and encourage them to take photos of their angel.