Maternal Newborn Part 3

Clara Guidry Room 301 Clara Guidry, Mrs. Clara Guidry is a 34 y/o G5P4 who gave birth to a 9lb. 3 oz male infant following a 12hour elective oxytocin induction of labor. She had an uncomplicated labor, epidural anesthesia and a rapid second stage, no episiotomy or perineal lacerations. Indwelling urinary catheter was removed prior to delivery. She is now one hour postpartum and is breastfeeding her baby. An IV of 1000 mL Lactated Ringers is infusing at KVO rate with an infusion of Lactated Ringers with oxytocin 20 Units infusing IVPB at 125 mL/hour. Upon entering her room, she tells you that she “feels wet”, and may have urinated on herself since she is still numb from the epidural and unable to move legs. Your assessment reveals blood pooling under buttocks onto the underpads with numerous large clots. She is anxious, appears pale, and complains of feeling light-headed. Her husband is at her bedside. Educational Needs Fall Risk Health Change Pain Level Psychological Needs Sensorium Physiological Increased acuity Increased acuity Increased acuity Normal acuity Increased acuity Increased acuity Status assessment reports uterine atony and bleeding and need for fundal massage. Status assessment reports patient is still numb from epidural and unable to move legs. Status assessment reports pooling of blood with large clots. Status assessment does not indicate report of pain and patient is still under effects of epidural anesthesia. Status assessment reports pooling of blood, patient reports feeling light-headed, appears pale, indwelling urinary catheter removed and patient unable to sense need to void. Status assessment reports patient reporting feeling light-headed and still numb from epidural and is feeling anxious. Your Respons e Explanation False Status assessment reports lingering numbness from epidural. True Status assessment reports blood pooling under buttocks with large clots, most likely secondary to uterine atony because of multipara status, rapid second stage, oxytocin use and large infant. True Status assessment reports blood pooling under buttocks with large clots. Description Acute Pain Bleeding Deficient fluid volume related to uterine atony/postpartum hemorrhage Impaired mobility True Impaired patterns of elimination False Status assessment reports effects continued numbness from epidural. Status assessment reports continued numbness from epidural with urinary catheter having been removed previously; patient unable to sense a full bladder which can contribute to uterine atony and hemorrhage. True Status assessment reports blood pooling under buttocks and large clots, feeling anxious and light-headed and appears pale False Status assessment reports no indication of a current infection. False Status assessment reports no indication of increased risk. Ineffective tissue perfusion related to hypovolemia Infection Nausea Safety Description Deficient knowledge Disturbed sensory perception Fall, risk for self and risk for dropping Your Respons e Explanation True Status assessment reports patient reports feeling wet and may have urinated on self and still numb from epidural; unaware of potential for uterine atony and hemorrhage, client and husband both require education and support. True Status assessment reports patient is still numb from epidural. True Status assessment reports lingering numbness from epidural and unable to move legs; reports feeling light-headed Description baby Impaired maternal newborn bonding Peripheral Neurovascular Dysfunction 1 Your Respons e Explanation False Status Assessment reports mother is currently holding and breastfeeding baby. False Status assessment reports no indication of increased risk. 1Assist mother to unlatch infant from breast and place infant in crib or hand to the husband. 2Massage uterine fundus. 2 3Call for help using emergency call system. 4Set oxytocin rate to Bolus on IV pump 4 as ordered by healthcare provider. 3 5 5Assess bladder status and need to perform straight catheter. 1 1Educate patient regarding indwelling urinary catheter placement, Wash hands. 2 2Insert indwelling urinary catheter and connect to collection bag, secure to Patient is light-headed and hypovolemic putting infant at risk of falling from mother’s arms. Infant safety is a first priority. Massaging the fundus until firm and tightly contracted closes off blood vessels at the placental site and stops bleeding. This can be done quickly prior to calling for help. Postpartum hemorrhage is the leading cause of morbidity and mortality requiring a rapid, team approach to patient management. Rapid infusion of oxytocin causes a sustained contracted uterus, thereby clamping off blood vessels from placental site and preventing hemorrhage. A full bladder displaces the uterus and contributes to hypotonia and uterine atony. Her uterus is slightly deviated to the right, indicating a potential need for catheterization. Education allows for planning and implementation of patient care; washing hands prior to indwelling urinary catheter placement prevents nosocomial infection during invasive procedure and is the first step. Insertion of Indwelling urinary catheter is done according to established protocols, under sterile technique and is the second step. patient’s thigh. 3Measure urine return in collection bag; Reassess uterine tone, response to massage, level in relation to umbilicus, and position in abdomen. 4Reassess vaginal bleeding and presence 4 for clots; change underpads as needed. 3 5 5Wash hands, document findings and completion of procedure. 1 Reassess vital signs. 2 2 3 3 A firmly contracted uterus clamps off blood vessels at the placental site, preventing uterine atony and excessive bleeding, changing underpads for patient comfort and prevention of infection. Prevents spread of infection; accurate documentation is to be performed after patient care is performed, NEVER BEFORE! Indicates physiologic response to fluid resuscitation and uterotonic meds, BP must be assessed prior methergine administration. Set plain Lactated Ringers to Bolus rate on IV pump. Administer Methergine 0.2 mg IM per healthcare provider order. 4 Assist healthcare provider with exam to assess for cervical or vaginal lacerations/hematoma or retained placental pieces. 5 Anticipate laboratory studies: CBC, blood typing and crossmatch, coagulation studies. 4 5 The patient is unable to void, and a full bladder is a common cause of uterine atony and early postpartum hemorrhage. Assesses adequate emptying of bladder; emptying bladder returns uterus to normal and position and facilitates normal contraction of the uterus. 1 Administer Oxygen via nonrebreather face mask at 10- Hypovolemia from blood loss and decreased perfusion decreases circulating oxygen levels to brain and Next the nurse must address fluid resuscitation to treat hypovolemia and fluid loss. Methergine causes a sustained firm contraction of the uterus, clamping off blood vessels at the placental site, decreasing excessive bleeding. Unrecognized cervical/vaginal lacerations from a rapid second stage labor and large fetus can be the cause of excessive vaginal bleeding, especially with a firm fundus. Laboratory studies reveal degree of hemorrhage, coagulopathies which can cause hemorrhage and aid in patient management. 12L/min. 2 2 3 3 4 4 5 5 other vital organs. Oxygen is a priority. Assist healthcare provider with administration of misoprostol (Cytotec) 1000 mcg rectally. Establish an additional IV line and anticipate additional crystalloids (Lactated Ringer’s), colloids (albumin), blood and blood products. Continue to closely monitor vital signs, uterine fundus tone/level and vaginal bleeding. Anticipate healthcare provider insertion of postpartum balloon and/or return to operating room. 1 Use therapeutic communication/active listening to assess patient’s concerns and interest in pumping for colostrum. 2 2 3 3 Causes a sustained firm contraction of the uterus, clamping off blood vessels at the placental site, decreasing excessive bleeding. This medication may be given quickly via rectum while obtaining other IV line. Fluid resuscitation and blood administration is critical to restoring blood volume and successful management of woman with postpartum hemorrhage. Indicates physiologic response to fluid and blood resuscitation, uterotonic meds and postpartum balloon with rapid installation components. Balloon exerts inward to outward pressure against the uterine wall, resulting in a reduction in persistent capillary and venous bleeding from the endometrium and myometrium. Active listening allows patient to express herself concerning choices of infant feeding and should be done first. Consult Lactation Consultant or provide education to patient and assist with pumping. Discuss with patient’s partner for willingness/interest to feed baby colostrum. Provides expert assistance in learning new skill. Allows choices in infant feeding and promotes 4 Assist partner in feeding pumped colostrum and partner skin-to-skin contact. Assess patient’s ability to hold infant and assist patient with holding baby skin-to-skin after feeding for maternal-infant bonding. 4 5 5 Cindy Mason Room 302 Cindy Mason, 28 y/o G2P1 at 40 weeks gestation. She and her husband present to OB Triage with complaint of early labor. Her prenatal history indicates an uncomplicated first pregnancy with a spontaneous vaginal delivery. Her current pregnancy has also been uncomplicated with no risk factors identified. She and her husband have attended Lamaze Prepared Childbirth classes and their Birth Plan indicates a desire for an unmedicated labor and birth and breastfeeding. Mrs. Mason states her contractions are occurring every 4 minutes and lasting 60 seconds. She is using slow-chest breathing and rates her pain at 4/10. She also reports leaking clear fluid from her vagina. She believes the leaking began about two hours ago. Category Educational Your response Increased Explanation Status assessment reports attendance at Lamaze classes and previous vaginal delivery, but may benefit from paternal-infant bonding. Promotes confidence in learning a new skill. Facilitates maternalinfant bonding and confidence in maternal role. Category Needs Fall Risk Health Change Pain Level Psychological Needs Sensorium Your response acuity Increased acuity Increased acuity Increased acuity Increased acuity Normal acuity Explanation additional coaching for labor management Client is at full term of pregnancy and has a changed center of gravity. Status assessment reports active labor with possible spontaneous rupture of membranes. Status assessment reports frequent contractions with pain score 4/10. Status assessment reports active labor with desire for unmedicated labor and birth. Status assessment reports no indication of increased sensorium acuity or changes in level of orientation. Maria Sanchez Room 303 Maria Sanchez, 20-year-old female, G1 T1 P1 A0 L1, 39 weeks gestation. Pregnancy uncomplicated. O+, Rubella immune, GBS negative. NKDA. 12-hour 1st stage, 1 hour 2nd stage, 10 minute 3rd stage. Spontaneous vaginal delivery with 1st degree perineal laceration one hour ago. Vital signs stable; fundus firm, midline, at umbilicus; Lochia rubra moderate, no clots; Up to bathroom x1- 500 mL, no dysuria, instructed on peri-care; Legs still a little “tingly” but able to bear weight with assist X2. Pain level 3/10- ice to perineum with relief. Neonate male- Juan- 3500 g; Apgar 8 & 9; T 36.8 degrees C; AP 156 beats/minute, regular; R 52 breaths/minute, irregular. Skin-to-skin with mother for first hour. Beginning to show hunger cues. Their plan is do both breast and bottle feeding; “las dos cosas.” Maria’s husband Raul is a quiet presence. Her mother, grandmother, and older sister were Maria’s support persons in labor. Maria and Raul are bilingual in English and Spanish. They were both born in the US- are Mexican Americans. Her mother speaks and understands more English than her grandmother does. Category Educational Needs Fall Risk Health Change Pain Level Psychological Needs Sensorium Your response Explanation Increased acuity Status Assessment reports r/t first postpartum and newborn experience Increased acuity Status Assessment reports r/t 1 hour postpartum; legs “tingly” from epidural in labor Increased acuity Status Assessment reports r/t 1 hour postpartum- first baby Increased acuity Status Assessment reports r/t perineal discomfort; 1st degree laceration Increased acuity Status Assessment reports r/t new experiences of postpartum Normal acuity Status Assessment reports Alert and oriented but tired Jessica Wu Room 304 Jessica Wu, 35-year-old Asian female, G3 T2 P2 A0 L2, 35 weeks gestation. NKDA. Previous pregnancies uncomplicated but Cesarean births d/t persistent breech position. Smoker x 15 years but states she “cut back to 3 cigarettes/day during her pregnancies.” Reports that she started smoking during college. States started having moderate amount of bright red bleeding about 0800. Came to the hospital after dropping the older children at school (5 and 7 years old). She has called her husband and he is meeting her at hospital because he was already at work. It is now 0945. She is anxious about the bleeding. States she “never had anything like this with her other pregnancies!” Denies pain, contractions, or leaking of amniotic fluid. Category Your response Educational Needs Increased acuity Fall Risk Increased acuity Health Change Increased acuity Pain Level Decreased acuity Psychological Increased Needs acuity Sensorium Normal acuity Explanation Status assessment reports r/t change in condition and bleeding Status assessment reports r/t 35 weeks gestation (third trimester and changed center of gravity) Status assessment reports r/t complication of pregnancy and bleeding. Status assessment reports No pain or contractions noted in the report. Status assessment reports r/t concern about condition and stress related to the unknown outcome of this new change Status assessment reports alert and oriented X4. Drove herself to hospital.