Mother Baby Postpartum Notes

Mother Baby Notes Mnemonics Maternal Fetal Distress Preterm Labor Drugs “L.I.O.N.” “It’s not my time” Left side Initiate IV fluids Oxygen via face mask Notify the doctor Indomethacin (NSAID ) Nifedipine Magnesium sulfate Terbutaline Fetal Heart Rates “Veal Chop” Variable deceleration = Cord Compression Early deceleration = Head compression Accelerations = Oxygenation is okay Late deceleration = Placental insufficiency (bad sign) DIC TEAR Common causes of DIC Delivery TEAR Infection (gram neg) Cancer: prostate, pancreas, lung, stomach Obstretical complications Toxemia of pregnancy Emboli (amniotic) Abruptio placentae Retain fetus products Mnemonics cont. Neonatal Resuscitation “MR. SOPA” Mask adjustment Reposition airway Suction Open mouth Pressure increase Alternate: LMA/ ETT (NG first) Post-Resus Targets “STABLE” Sugars Temperature Airway Breathing Labs (CO2 45-55) Emotional Support POST-birth Signs (call 9-11 or Go to ER) “POST” Pain in chest Obstructed breathing or SOB Seizures Thoughts of harm to self or baby Post-BIRTH Signs (call healthcare provider or clinic) “BIRTH” Bleeding that soaks through one pad/hour or blood clots the size of an egg or bigger Incision that is not healing Red or swollen legs that is painful or warm to tough Temp of 100.4F or higher Headache that does not improve, even after taking meds or worsens with vision changes FETAL HEART RATE ABNORMALITIES The fetal heart rate is less than 120 bpm. This is a nonreassuring. Causes of this may include postdate pregnancy and/or abnormal fetal presentation. Severe bradycardia can include prolapse of the umbilical cord, uterine tetany, precipitous delivery, and prolonged compression of the umbilical cord, etc. A heart rate below 80 bmp for more than 3 minutes requires immediate delivery to reduce risk of acidosis, hypoxia or asphyxia. This is a reassuring sign. Some causes of this can include stimulation of the fetal scalp, fetal movements, and/or cervical examination, etc. This may require an evaluation with a non-stress test. This is caused by contractions during labor and are linked to placental insufficiency. The causes of this includes postdate pregnancy, gestational diabetes, chronic hypertension, and/or hypovolemia, etc. This requires immediate evaluation of the fetal PH levels. Fetal heart rate is above 160 bpm. This is a nonreassuring. If tachycardia last for more than 10 minutes this is a sign of fetal distress. However, this is not severe unless there is decreased variability. Some of the causes for tachycardia include fetal hypoxia, maternal fever, maternal anemia, prematurity, and chrorioamnionitis, etc. This is caused by the compression of the head of the fetus during labor. This is reassuring and is not linked to any fetal distress. This happens when the fetal heart rate drops sharply. This is a nonreassuring sign. This is seen with preterm rupture of membranes and oligohydramnios, fetal acidosis, and/or distress. Complications of Labor Preterm Premature Rupture of Membranes (PPROM) This is when the rupture of membranes is before 37 weeks of gestation. Causes: Trauma Multiple gestation Polyhydramnios invasive procedures (amniocentesis, and/or, cord blood sampling, etc) Complications: Chrorioamnionitis (chorio) Postpartum endometritis Neonatal sepsis, Preterm delivery , etc Treatments: Depends on the stage but it can include best rest and tocolytics, magnesium sulfate and dexamethasone to protect the brain, and/or immediate delivery may be needs for unstable fetal heart rate or chorio. Prolonged Rupture of Membranes This is the rupture of membranes for more than 24 hours. Complications: Chrorioamnionitis (chorio) Maternal fever, tachycardia and foul-smelling vaginal discharge Hypotension Septic Shock Treatments: Immediate delivery of the fetus Mother is treated with antibiotics Newborn is monitored closely for neonatal sepsis Complications of Labor (cont) Meconium Aspiration Syndrome After delivery newborn may have the following signs and symptoms; nasal flaring, tachypnea, chest retractions, and/or cyanosis, etc. Causes: Stress during the labor Compression of the umbilical cord Placental insufficiency Treatments: Neonatal resuscitation with intubation (or ventilation) as needed, supplemental oxygen, and/or use of IV antibiotics Chrorioamnionitis Risk Factors/ Causes: Premature rupture of membranes Fetal distress Frequent cervical examination/ internal fetal heart monitoring Prolonged rupture of membranes Characteristics: Maternal tachycardia Fever/ Chills Foul- smelling vaginal discharge Septic shock, etc Complications: Neonatal sepsis Cesarean delivery Postpartum hemorrhage Placental abruption Endometritis Treatments: IV antibiotics, antipyretics and deliver the newborn Complications of Labor (cont) Abruptio Placenta When the placenta detaches itself from the uterine wall Signs Abruptio Placenta Placenta Previa Sudden PAINFUL bleeding, dark- red or bright red in color, uterus is rigid and tender Sudden PAINLESS bleeding, bright red in color Placenta Previa The placenta is covering or near the cervix, blocking the opening to vagina. Risk Factors Complications Treatments HTN, smoking, drug abuse, trauma to abdomen, PPROM Decreased oxygen saturation to fetus, premature birth, DIC, blood clot, hypovolemic shock Bed rest, may require emergency csection if term, blood transfusion, oxygen, IV fluids Maternal hemorrhage, premature labor, fetal malpresentation , increased risk for placenta accreta. Bed rest, may require emergency csection if term, IV dexamethasone for less than 34 week gestation to expedite the maturity of the fetal lungs. Previous csection, older maternal age, multiparity, multiple gestation, smoking For both conditions they will require these 3 interventions: Frequent vital signs Fetal ultrasound Fetal heart monitoring Complications of Labor (cont) Precipitous Delivery This is when baby is born within three hours of when contractions started. (rapid labor) Causes: Multiparity History of previous precipitous deliveries Small for gestational age (less than 10th percentile) Complications: Postpartum hemorrhage Uterine atony Prolapse of umbilical cord Respiratory distress to newborn Shoulder dystocia Meconium aspiration syndrome Prolapsed Cord This is when the umbilical cord slips down in front of the baby after the water breaks. Complications: Fetal distress Variable deceleration Acidosis Treatments: Preparations should be made for c-section delivery dic AND hellp syndrome DISSEMINATED iNTRAVASCULAR cOAGULATION An excessive generation of thrombin in the blood; often causes embolism. Causes: Preeclampsia Abruptio placentae Hemorrhage Severe maternal sepsis (especially gram negative bacteria) Signs and Symptoms: Bleeding episodes, thromboembolism, tissue hypoxia, etc Treatment: Oxygen IV fluids Blood, platelet, or fresh frozen plasma transfusions hellp syndrome Life threatening pregnancy complication Hemolysis, Elevated Liver enzymes, Low Platelet count Causes: Seen in severe preeclampsia or eclampsia Multiparity Maternal age greater than 35 years old Signs and Symptoms Nausea / Vomiting Epigastric pain from liver distention Hypertension Right upper quadrant abdominal pain Proteinuria Treatment: Delivery of fetus and placenta Magnesium sulfate for seizure prevention Antihypertensive medications IV fluids POSTPARTUM ASSESSMENT Remember “BUBBLEHE” B Breast Monitor size, shape, engorgement, redness, cracking. Recommend a support nursing bra. U Uterus Assess each postpartum day, should reduce everyday B B L E h E Provide stool softener or suppository as needed, listen for bowel sounds. Bowel Bladder Encourage bathroom frequently to avoid distention and heavy bleeding (postpartum hemorrhage) Lochia Episiotomy Monitor the amount, odor, color, and clots. Goes from dark red, pink, to clear. Bleeding last for about 6 weeks postpartum REEDA Redness, edema, ecchymosis, discharge, approximation Homan’s Sign Emotional Status Monitor for calf pain, redness, and swelling (edema). Palpate pulses. Monitor for signs of postpartum depression & bonding. Postpartum Hemorrhage Normal fundus should be firm, midline and right at the umbilucs Abnormal is a boggy (soft) fundus, not midline. Vaginal delivery- blood loss of more than 500 or 1000mL (depending on hospital policy). Cesarean delivery- blood loss more than 1000 mL Think of the 4 T’s Tone Lack of uterine tone AKA uterine atony. (soft and boggy uterus). Causes: multiple pregnancies Unable to empty bladder muscle fatigue from delivery Treatment: Fundal massage Urination (or placing a catheter) medications or surgery Tissue Retained placental fragments in the uterine cavity Retained placenta— prevents contractions — which leads to uterine atony. Trauma Damage to genital structure (uterus, cervix, vaginal, perineum) Examples: C-section incision From pushing baby from the vaginal canal Medical instruments (forceps, vacuum, episiotomy) Emergency Needs to be repaired right away Apply pressure Stitch up laceration Thrombin Blood clotting condition Could be genetic obstetrical (eclampsia, placental abruption) Can lead to disseminated intravascular coagulation (DIC) Postpartum cOMPLICATIONS/ pROBLEMS bLADDER dISTENTION/ uRINARY rETENTION This can happen because of trauma to the bladder and/or urethra. Some interventions VVVV hydration and catheterizations. to help this would be early ambulation, sitz baths, hEMORRHOIDS This usually resolves after delivery. Some interventions to help with this would be corticosteroid creams and witch hazel for some relief. pERINEAL eDEMA AND PAIN After delivery, women experience pain and edema in the perineum. This worsen when women have tears/lacerations and/or episiotomy. Some interventions includes use of ice compression in the first 24 hours, NSAIDs, dermoplast spray, witch hazel, and sitz bath. BREAST ENGORGEMENT This is when the breast are painful, swollen and tender because they are overfilled with milk. The interventions for the mothers would be to breastfeed or pump more frequently. cONSTIPATION This is common with majority of the postpartum women. Some interventions include hydration, high fiber diet, stool softeners, laxatives, and/or early ambulation, etc. sPINAL hEADACHES This is caused by the leakage of spinal fluid through a puncture hole in the membrane that surrounds the spinal cord. This is a dull, throbbing headache that worsens when sitting up and moving but gets better when laying down. It’s caused by epidural and spinal anesthesia. Some interventions include recumbent position and giving analgesics, drinking caffeine and/or getting a blood patch by anesthesia. C-section Incision Wound care begins in the hospital. The dressing is removed per hospital policy. It is examined for bleeding, dehiscence and drainage. Women need to be educated to clean the incision with soap and water and pat it dry. It should be kept dry at all times to prevent any infection. Postpartum cOMPLICATIONS/ pROBLEMS Lacerations There are four types of lacerations: 1st degree tear, 2nd degree tear, 3rd degree tear and 4th degree tear Risk Factors: Precipitate labor Prolonged labor Nulliparity History of perineal tears Complications: Postpartum hemorrhage Postpartum endometritis Fistula Risk of tears in future deliveries Treatment: Immediate repair Adequate analgesia Perineal wound care Postpartum Depression Depressed mood that can last from days to weeks. Can cause sadness, crying, anxiety, forgetfulness, insomnia, headaches, restlessness and more. Usually resolves within the 2nd week of postpartum. This happens within the 1st year of postpartum. This can resemble acute psychosis such as hallucinations, delusions, and mania. Supervision by a psychiatrist, hospitalization and management are needed. This can last months. This can be screened with a postpartum depression screening such as the Edinburgh Scale. All signs and symptoms may differ from one mom to another. Some include insomnia, loss of libido, loss of appetite , pessimism towards the newborn. Majority of the time a psychiatrist is involved especially if they are suicidal, homicidal loss of interest in the newborn and or drug abuse. May need treatment with antidepressants. Risk factors for all: Some may include unwanted pregnancies, low selfesteem, drug abuse, lack of support from family or friends, unmarried or single mothers, history of prior postpartum depression or baby blues. Breastfeeding Encourage breastfeeding on demand (feeding cues) Different positions for breastfeeding: cradle, cross-cradle, side lying, football hold Discourage pacifier use until latch on established. Proper latch on (this scale is used to score the latch) LATCH : Breastfeeding Charting System (shown in next page) The higher a LATCH score the more likely they will be successful with breastfeeding. A lower LATCH score the more help they need; lactation consults will be recommended Assessments: Assess the mother’s position, make sure she’s comfortable Assess the infant’s position Assess the mother’s hand when she grasps her breast to make sure she is not impeding the infant’s latch on the areola. Ensure the infant’s lips are above the nipple; the lower lip should be flanged. Assess as the mother presents the breast to the infant and how the infant latches and suckles. Listen for sucking and swallowing sounds Ensure the mother is not in pain (If painful that may indicate a bad latch, you need to delatch the infant and try again). Latch Scoring 0 Latch Too sleepy or reluctant No latch established 1 2 Repeat attempts Hold nipple in mouth Stimulate suck Grasps breast Tongue down Lips flanged Rhythmic sucking Audile Shallowing None A few with stimulation Spontaneous and intermittent <24 hours old Spontaneous and frequent >24 hours old Type of nipple Inverted Flat Everted (after stimulation) Comfort (Breast/ Nipple) Engorged Cracked/ bleeding/ blisters or bruises severe discomfort Filling Reddened/ blisters or brusies Mild or moderate discomfort Soft Nontender Hold (Positioning) Full assist (staff holds infant at breast) Minimal assist Teach 1 side; mom does the other Staff holds and mom takes over No assist from staff Mother able to position/ hold infant independent Breastfeeding Challenges Engorgement This is when the breast are painful, swollen and tender because they are overfilled with milk. Management include increase breastfeeding, express milk by using a breast pump or hand expression, apply warm compression before feedings, apply ice packs after feedings, and use a well-fitted supportive bra, etc. Blocked Ducts This is a small tender lump in breast tissue. It’s caused by an overabundant milk supply, constricting bra, and/or incomplete emptying of the breast. The management includes applying a hot pack, massaging the affected breast before and after feedings, breastfeed frequently, begin feeding on affected side and/or avoid constructing clothes, etc. Sore and Cracked Nipples This is caused by ineffective latchon. Assess and correct positioning and latch during a feeding session. Management include clean breast with warm water, use warm water compresses for pain, and apply ointment such as lanolin cream, etc. Moms can use a nipple shield if there is bleeding, they need to be educated on how to use it. Mastitis This is a painful infection of the breast tissue. Moms can have a fever greater than 100.4F, increased fatigue, flu-like symptoms, pain and swelling at the breast, redness, hot and hard area. The managements include continuing the breastfeed, start on unaffected side and switch when let down occurs, rest, fluids, analgesics, and/or antibiotics, etc. Shortened Frenulum Shortened frenulum or tongue tied infants required the expertise of an ENT specialist to do a frenotomy. Formula Supplementation Reasons For Supplementation: Birth weight less than 1500 g Born at less than 34 weeks Risk for hypoglycemia or jaundice Maternal (positive HIV infection) Maternal request Infant having human milk intolerance , etc. education: Amount Offer 1/2 ounce every 3 to 4 hours for the first 24 hours Increase by 1/2 ounce after 24 hours Volumes should only be increased every 3-4 feeds Positioning Infant should be at a 45 degree angle Infants should be held upright for 15 minutes after a feeding Take short breaks during the feeding. Burp the baby Expressing/ sTORING bREAST milk Breast milk is expressed with breast pump or by hand expression. It should be stored in appropriate breast milk storage bag on bottles. Make sure to label the milk by time and date Room temperature: Expressed milk can last 4 hours Refrigerator: Can last 4 days Freezer: Can last for up 6 to 12 months When storing in fridge or freezer, store it away from the door; will preserve the milk from temperature changes Thawing: Thaw the oldest stored milk first Can thaw the milk overnight in the fridge or by running it under lukewarm water Do NOT place in microwave Thawed milk should be used with 24 hours Do NOT refreeze after it has been thawed; discard it. N ASSESSMEN N R O B T EW APGAR 7-10: excellent condition 4-6 : moderately depressed 0-3: severely depressed Priority Goals: 1st is AIRWAY *Use bulb syringe or deep suction 2nd is WARMTH *immediately dry with blanket or place under warmer VITAL SIGNS BLOOD PRESSURE (BP) MAP Systolic : 60-80 mmHg Diastolic : 40-50 mmHg Equal to the # of weeks gestation or higher HEART RATE (HR) 110- 160 bpm RESPIRATORY RATE (RR) TEMPERATURE ! 30-60 breaths/ min 97.7 to 99.5 F (36.5 to 37.5 C) Look out for signs of respiratory distress grunting , retractions, nasal flaring, etc. Umbilical cord Consist of 2 ARTERIES and 1 VEIN Think “AVA” Head Caput Succedaneum: think caput = cap Collection of fluid DOES cross the suture line Cephalohematoma: Collection of blood Does NOT cross the suture line Molding: Due to pressure, newborns may have an abnormal shape head. This is normal Fontanelles: Normal findings are flat and soft. Abnormal: buldging (increased ICP) and sunken (dehydration) Physical Assessment (system review) Skin Assess the skin for pallor, cyanosis, jaundice, signs of dehydration, petechiae rashes. VVVV Normal findings would be mongolian spots, stork bites, newborn rash, and birth marks, etc. Head and NECK Palpate the head to feel for the fontanelles, they should be soft and flat. You are assessing to makes sure the head is normal and there is no caput succedaneum, cephalohematoma, molding, microcephaly or macrocephaly. cARDIOVASCULAR Assess cardiac and breath sounds. Assess for - any murmurs. Listen to the heart rate making sure heart rate is within normal range. rESPIRATORY Count the respiratory rate and assess the chest wall for symmetry. You are assessing for any signs of respiratory distress such as retractions, flaring, and grunting. aBDOMEN AND pELVIS Assess abdomen for shape making sure it’s symmetrical and not distended. Palpate for hernias and assess the patency of the anus. Examine to penis and testes for any abnormal signs such as epispadias, hypospadias, enlarged testes, and torsion, etc. MUSCULOSKELETAL Examine upper and lower limbs making sure all 4 extremities are symmetrical and have mobility. You can do the newborn reflexes as shown of the next page. - Newborn Reflexes Moro/startle reflex Extend the baby halfway to a sitting position from supine and suddenly let the head fall back. Tonic neck reflex When laying down, the head is turned to the left or right, the corresponding arms extends while the other arm bends to their head. Think of this as “fencing reflex” Palmar/ Grasping reflex Newborn should pull on a finger when it is placed in their palm. Rooting reflex Newborn should turn their head when and open their mouth if their cheek or corner of mouth is touched. Plantar/ Babinski reflex Newborn fan their toes downward when the outer edge of the sole of the foot is stroked upwards toward the toes. Sucking reflex Newborn suck if a finger is placed in their mouth. '- - newborn education Cord care The umbilical cord clamp is removed after the cord is dry. Make sure to fold diaper underneath the cord to allow drying; leaving the cord exposed to air and observe for redness, drainage and odor. Educate to not remove stump and to let it fall off on its own. Elimination You want at least 1 pee and poop diaper within the 1st 24 hours of life. Then it increases each day. You make see orange or pink tint in the diaper which indicates urate crystals; these crystals develop since the urine is concentrated until they start drinking more fluids. Circumcision This procedure is optional. It is done with local anesthetia with the first week of birth. Make sure they have their Vitamin K shot before procedure is done. May be delayed if the newborn has - disorder affecting the penis. Parents need hypospadias, or any to be educated on how to care for it with A&D ointment. CHD screening Pulse oximery needs to be done to screen for congenital heart car seat Sleep Safety disease (CHD). This screening is done 24 hours after birth. The oxygen saturation is taken on the right hand and right foot, cannot have a difference of 3% between both. If they fail the procedure the pediatrician will order some extra test such as an echo, chest x-ray and/or cardiac evaluation. A car seat challenge is done to newborns who are preterm (less than 37 weeks gestation). This procedure is used to screen for respiratory distress while in the car seat. The newborn would be placed in the car seat and would be monitored (oxygen saturation, heart rate, respiration) for 90 minutes. Sleep safety is extremely important to prevent sudden infant death syndrome (SIDS). They should be placed in prone position while asleep, in a flat mattress with no extra beddings, bumper pads, pillows or loose toys around the baby. No sharing a bed, they should be in their own safety approved crib or bassinet. Common newborn medications —- - - Oral sucrose Eye Prophylaxis Vitamin K HBIG / Hepatitis B This is used as an analgesic for a painful procedure such as a heel prick, echo, circumcision, etc. This oral sucrose is applied to the anterior part of the tongue. This is only for a temporary solution, this is not to be used for chronic pain. This vitamin is required to help with the blood clotting factors for the infant. This is administered via an injection on the infants thigh. Vitamin K is extremely important to maintain healthy hemostasis. Some parents may refused this but it’s required especially if the parents want their newborn circumcised. The eye ointment is called Erythromycin. This ointment is used to prevent infection to the newborn against chlamydia and gonorrhea. It is applied directly after delivery. HBIG is given directly after delivery to the newborns who moms have been exposed or have Hepatitis B. The Hepatitis B vaccine is recommended 24 hours of life. Parents should be educated on the benefits of receiving this vaccine as most don’t know what some vaccines do and for that reason they tend to refuse them. Resuscitation and stabilization A quick assessment should be done to determine is the newborn is stable or if it needs resuscitation. The 3 most important questions you need to think about is: Is the infant term? Is the infant crying or breathing? Does the infant have good muscle tone? *If all of these are true, infant should be dried up and placed on mother’s chest for skin to skin. If there is a “no” for any of these, resuscitation is required and needs to be started immediately. Hyperbilirubinemia Elevated total serum bilirubin level. If unchecked or untreated, it can lead to bilirubin encephalopathy or kernicterus. This is the most leading cause of hospital readmission during the 1st 2 weeks of life. Physiologic Jaundice Breastfeeding Jaundice This is common. This can be triggered by the short life span of the RBCs in newborns. This is seen in the 1st week of life. This can be because infants are not taking enough breast milk. Breast mILK jAUNDICE Pathologic Jaundice Late onset jaundice related to substances in the breast milk that can trigger the deconjugation of bilirubin. This is associated with hemolytic disease or impaired liver function. Have the following characteristics: Appears in the first 24 hours of life or after the 1st week of life Last more than 2 weeks Total serum bilirubin rises by more than 5 mg/dL in a day Signs and Symptoms: Yellow tinge in the eyes or trunk Poor feedings Lethargy/ too sleepy Treatment: Formula feeding can reduce the risk or lower bilirubin level Increase the frequency of feedings Phototherapy Hypoglycemia This is when the blood glucose level is lower than the normal range. Normal glucose levels in the neonate range in 40-60 mg/gl with a target of 45 mg/dl before each feeding. Risk Factors: Inadequate glycogen stores prematurity IUGR Low birth weight Small for gestational age (below the 10th percentile) Alterations in endocrine regulation Infant of a diabetic mother Large for gestational age (above the 90th percentile) Stressed or ill infant (respiratory distress, hypothermia, Sepsis) Signs AND sYMPTOMS Jitteriness Irritability / Lethargy Apnea, bradycardia, and/or cyanosis Tachypnea Poor suck or poor feeding Hypothermia Seizures Diagnosis Confirmed by a bedside serum glucose measurement with a glucometer. Treatment Give the infant glucose via syringe or per hospital policy and feed the infant immediately. Repeat the blood glucose in an hour, if its still low other interventions are needed. This may include IV dextrose, enteral feeding and/or IM glucagon. Notes Notes Notes Notes Notes