OB Exam #3 Study Outline

OB Exam #3- Study Outline -Week 7 + 8 – Postpartum and Newborn Care Chapters 15 & 16 Overview: Unit V focuses on the maternal adaptation during the normal postpartum period. Both physiologic and psychological aspects are explored. Parental adaptation is also consider. Nursing management includes assessment of physical and emotional status, promoting comfort, assisting with elimination, counseling about sexuality and contraception, promoting nutrition, promoting family adaptation, and preparing for discharge. Learning Objectives: Examine the systemic physiologic changes occurring in the woman after childbirth. Integrate dimensions of postpartum care for the multicultural family. Determine the psychological changes that occur in women in the postpartum period. Characterize the normal physiologic and psychological adaptations to the postpartum period. Compare and contrast bonding to the attachment process. Examine the role of the nurse in promoting successful breast-feeding. Plan areas of health education needed for discharge planning, home care, and follow-up. To Do List: Review Chapter 15 & 16 Review of Week 6 class PPT Review and watch Breastfeeding Resources (2 videos and 1 link) (See folder below) Work on ATI Maternal Newborn eBook Chapter Questions 10-16 Due @0600am Work on ATI Real Life RN Scenarios Postpartum Period-Can be referred to as puerperium From delivery of the placenta until the reproductive system returns to the non-pregnant state of 6-8 weeks Also known as the 4th trimester Vital Signs Assessment- Temperature: slight elevation during first 24 hours; normal afterward Pulse: 40 to 80 bpm; puerperal bradycardia Respirations: 16-20 breaths per minute Blood pressure: within normal range Pain: goal between 0-2 on pain scale Typical Assessments in Postpartum PeriodFirst hour- every 15 minutes Second hour- every 30 minutes First 24 hours- every 4 hours After 24 hours: every shift unless there is a problem Cardiovascular and NeurologicHeart rate and stroke volume stay increased after delivery, will decrease gradually – may take up to 12 weeks Cardiac output decreases after 48 hours Blood volume changes return to prepregnant within 6 months Respiratory tidal volume returns within 1-2 weeks Carpal tunnel during pregnancy resolves Headaches Endocrine- estrogen and progesterone levels drop quickly, prolactin levels decline within 2 weeks if not breastfeeding Hormonal shiftsR/O (rule-out) preeclampsia, R/O spinal headache- blood patch needed? Musculoskeletal (mom)Abdominal muscles protrude for several days – most resolve within weeks (consider # of pregnancies, time between pregnancies) Hyperpigmentation of skin all resolve within a few weeks Diaphoresis: hormone shifts cause elimination of excessive fluid to start releasing within 24 hours Leave foley in until the next day Hair loss: estrogen returns to pre-pregnant within 6-12 months Bladder & Urinary Changes: Diuresis: occurs within 12 hours postpartum due to drop in estrogen Decreasing production of aldosterone- the hormone that decreases sodium retention and increases urine production Diminished bladder tone – c-section especially Distention/retention Stress incontinence Mild proteinuria 1-2 days postpartum: breakdown of protein in uterine muscle BUN rises with involution GFR, renal blood flow and creatinine normalizes within a month postpartum Pitocin that may increase fluid retention and delay diuresis Nursing: encourage mom to void every 2-3 hours-avoid a full bladder Use peri bottle, change pads frequently, sitz bath, encourage lots of fluids, breathwork Bowel changesdecreased muscle tone, lack of food during labor, dehydration (prelabor status), pain (hemorrhoids/trauma), anesthesia/analgesia = abdominal distention and delayed bowel movement Nursingencourage walking, increase fluids, increase fiber intake, assess for hemorrhoids, stool softeners Bowel Assessment: Inspect the women’s abdomen for distention, auscultation for bowel sounds in all 4 quadrants prior to palpation the uterine fundus, and palate for tenderness Ask the patient about daily bowel movement or has she passed gas since giving birth. Avoid mom being constipated Explain that mom should wipe from front to back after voiding or defecating Normal assessment findings are active bowel sounds, passing gas, and non-distended abdomen Bladder Assessment: Signs of Bladder Distention Location of fundus above baseline level (determine with empty bladder) Fundus displaced from midline Excessive lochia Bladder discomfort Bulge of bladder above symphysis Frequent voiding’s of less than 150mL each time Characteristics of Uterine Atony: Difficult to feel, boggy (soft) Fundal height usually above umbilicus Lochia is increased, may contain large clots True amount of blood being lost may not be immediately apparent until mom stands, fluid gushes out Collection of blood in the uterus further interferes with contractions/involution, worsening atony Uterine Hemorrhage: Early – within 24 hours postpartum Late- between 24 hours and 6 weeks postpartum Major risk is hypovolemic shock – interrupts blood flow to body, prevents normal oxygenation, nutrient delivery, and waste removal S&S: tachycardia, falling systolic blood pressure, pale, cold, and clammy skin, mental status changes, decreased urinary output GI System Adaptations: The GI system quickly returns to normal, relief of pressure on organs Decreased bowel tones for several days Decreased peristalsis occurs Constipation is common due to fear of straining affecting the perineum Gas pains common especially after c-section Initial Postpartum Assessment: Biggest concern- is mom bleeding too much Up to 2 hours after delivery of placenta Vaginal delivery- blood pressure, pulse, and respirations every 15 minutes times four, then every 30 minutes times two. Temp after delivery with routine vitals if normal range C-section- blood pressure, pulse and respirations q 15 minutes for 2 hours or more frequently depending on maternal condition. Temperature after delivery, end of recovery, and as condition warrants. Assess for pain after delivery, with vital signs and prior to transfer to postpartum care Palpate fundus and assess lochia q 15 min times two hours then q 4 hours x24 hours Assess bladder status hourly until first void If C-section, assess dressing/incision every 15 minutes times two hours Nursing assessment: full head to toe q shift, pedal pulses, edema, heart, lungs, Braden scale, SBAR Pain: Episiotomy, laceration Hemorrhoids Breast Incision After pains Constipation Complications Spinal headache Preeclamptic symptoms Infection (wound/endometritis) Comfort Measure Options: Nonpharmacologic- rocking chair, ice pack, heat pack, sound machine, peri bottle, essential oils, warm drinks, sitz bath, walking, chewing gum, abdominal binder Pharmacologic- Motrin, Tylenol, narcotics, dermaplast, tucks, dibucaine, PCA Nursing Assessment: Full head to toe assessment each shift Pedal pulses Edema Heart Lungs Braden scale SBAR Physical Assessment: Postpartum Period“BUBBLE HE” Breasts (size, contour, engorgement) Uterus (height of fundus, firmness) Bladder (voiding, bladder emptying) Bowels (bowel sounds, distention) Lochia (amount, color, odor) Episiotomy and perineum (lacerations, hematoma) Extremities – Homan’s sign Emotional status Homan’s Sign: Most evidence suggests Homan’s is not the most reliable indicator anymore for a DVT Rely on these key indicators: pain, edema, redness and or warmth – call OB and inform Best prevention is to encourage and help assist when needed with ambulation Patients with risk factors for clot may have lovenox ordered postpartum or SCD’s if on bedrest (magnesium sulfate patients) Breastfeeding Benefits: For baby: asthma, obesity, type 1 diabetes, ear infections For mom: ovarian cancer, breast cancer, type 2 diabetes, high blood pressure Lactation: Colostrum & BreastmilkColostrum- immunoglobulins, high in proteins and minerals, less fat than mature milk, laxative effect Breastmilk-usually comes in by day 5, mature milk by day 10 Adequate nutrition and hydration 500 kcal/day extra Lactation/milk expression: latching within 1 hour is best, or hand express or pump. Do this within 6 hours post-delivery to get best milk supply Lactation #1: secretion of milk by breasts, result of interaction of progesterone, estrogen, prolactin, and oxytocin Typically appearing 4 to 5 days after childbirth “Breast crawl” process Lactation #2: newborn sucking on breast - stimulates pituitary gland- causing release of prolactin and oxytocin- causing synthesis and release of breast milk in the breast and contraction of smooth muscle in the uterus and around the alveoli cells in the breast Breastfeeding latch: mouth covers areola, baby’s lips are flanged out Engorgement: Process of swelling of the breast tissue due to an increase in blood and lymph supply as a precursor to lactation Relieved by frequent emptying, warm showers, and compresses before feeding, cold compresses between feedings if breastfeeding Tight supportive bra, ice, avoidance of breast stimulation if not breast feeding Reproductive System Adaptations: Uterus: involution – contraction of muscle fibers; catabolism; regeneration of uterine epithelium Lochia: rubra, serosa, alba After pains Cervix: closure; now appearing as a jagged slit-like opening Vagina: eventual thickening and return of rugae Perineum Uterus - assess location and tone of uterus, midline or deviated, firm or boggy, height of fundus, delivery day vs. 3 days postpartum Fundal massage- fundal assessment is part of the routine postpartum assessment. If fundus is displaced laterally, have patient empty their bladder Involution: Fundal height descends 1-2 cm per day After the first week following birth fundal heights should be 4-6 cm below the umbilicus After 2 weeks fundus should not be palpable – below the symphysis pubis Oxytocin responsible for uterine afterpains/contractions Intermittent contractions/pain Additional contractions/afterpain associated with breastfeeding – release of oxytocin Contraction / afterpain stronger and more frequent with multipara HCG decreases – not detectable after 24 hours following birth Estrogen decreases Prolactin increases with breastfeeding Thyroid dysfunction (low) – s/s fatigue, depression, palpitations, irritability, impaired memory and focus Measurement: U=umbilicus U+1 = 1 cm above umbilicus U-1 = 1 cm below umbilicus Lacerations of the Reproductive Tract: Can occur in perineum, vagina, or cervix or around the urethra Vasculature bed in these areas is engorged Blood is usually brighter red than lochia and flows in a continuous trickle Uterus is typically firm Treatment: usually suturing Episiotomy – description, anticipated findings, unanticipated findings, interventions, nursing care, patient teaching Episiotomy & Laceration: Nursing Interventions Assessment Offer icepacks and topicals Tucks and dermaplast (numbing spray) Sitz bath and peri bottle Donut pillow (not extended use) Pharmacologic intervention Type of Lochia: Rubra Serosa Alba Color Red Pink, brown-tinged Yellowish- white Duration 1-3 days 3-10 days 10-14 days Characteristics Abnormal findings Possible small clots, contains blood Small amount of blood and and tissue fragments, fleshy odor WBC’s, tissue, fleshy odor Large clots (small, egg), saturated pad within one-hour, foul smell Description Anticipated findings Unanticipated findings Interventions – non-pharmacological + pharmacological Nursing care Patient teaching Episiotomy & Laceration: Nursing Interventions Assessment Offer icepacks and topicals Tucks and dermaplast (numbing spray) Sitz bath and peri bottle WBC’s, tissue, bacteria and epithelial cells, no strong odor Saturated pad, reappearance of Saturated pad, reappearance of red bleeding, foul smell pink or red bleeding, foul smell Donut pillow (not extended use) Pharmacologic intervention Postpartum Danger Signs: Fever greater than 100.4 Foul-smelling lochia or an unexpected change in color or amount Large blood clots or bleeding that saturates a peripad in an hour Severe headaches or blurred vision Visual changes, such as blurred vision or spots, or headaches Calf pain with dorsiflexion of the foot Swelling, redness, or discharge at the episiotomy, epidural, or abdominal sites Dysuria, burning, or incomplete emptying of the bladder SOB, or difficulty breathing without exertion Depression or extreme mood swings Postpartum Assessment: Cesarean Delivery Vitals q 4 hours for 24 hours and then q 8 hours until discharge Assess items below every 4 hours for 24 hours, then q shift or as condition warrants: -pain management (comfort level and response to medications/therapies) -uterus (location, tone) -lochia (color, amount, odor) -bladder (voiding/foley, distention, dysuria) -abdominal incision/dressing Every shift or as condition warrants, assess: -breasts (soft, firm, engorged, reddened, pain) -nipples (intact, tenderness, cracked, inverted) -breath sounds -perineum (edema, redness, pain, bruising, hematoma) - bowel -hemorrhoids (present, size, condition) -Lower extremities (edema, varicosities) and as necessary continued use of sequential compression devices -psychological, social issues and abuse to include postpartum mood changes C-Section Postpartum Care: Remove dressing after 24 hours or per provider order : -pressure dressing or aquacel dressing -staples out per MD order: -low transverse incision- usually on day 3 -classical incision- usually on day 7-14 (in office) Keep dry Don’t scrub, okay for water and mild soap Gauze (breathable) if drainage or sensitive Don’t use peripads to cover No creams/ointments/lotions Remove steri strips after discharge: 10 days Notify provider if redness, purulent or foul-smelling discharge Nursing Management in Postpartum Period: Nursing Interventions: Providing optimal cultural care Promoting comfort Cold and heat applications Topical preparations Analgesics Assisting with elimination Promoting voiding Promoting bowel elimination Promoting activity, rest, and exercise Early ambulation Rest periods Exercise program; recommended exercises; Kegel exercises Assisting with self-care measures Ensuring safety Counseling about sexuality and contraception Factors Affecting Family Adaptation to Parenthood Discomfort Exhaustion Comfort with infant Maternal age Cultural beliefs: cultural vision Personality Support Birth experience Variables Affecting Maternal Role Attainment: Maternal: Confidence, age, relationship with father, socioeconomic status, birth experience, stress, support systems, personality traits, self-concept, childrearing attitudes, role strain, health status, preparation during pregnancy, relationship with own mother, depression, and anxiety Infant: appearance, responsiveness, temperament, health status Four Stages of Becoming A Mother: Commitment, attachment to unborn baby, preparation for delivery and motherhood during pregnancy Acquaintance/attachment to infant, learning to care for infant, and physical restoration 2-6 weeks post delivery Moving toward a new normal Achievement of a maternal identity through redefining self to incorporate motherhood (around 4 months) Maternal Psychological Adaptations: Attachment: formation of a relationship between a parent and his or her newborn through a process of physical and emotional interactions Early and sustained contact between newborns and parents is vital Nurses play a crucial role in assisting with this process of attachment Factors influencing attachment include environmental circumstances, newborn health, and quality of nursing care Engrossment: Partner Psychological Adaptation #1 Visual awareness of newborn Tactile awareness of newborn Perception of newborn as perfect Strong attraction to the newborn Awareness of distinct features of the newborn Extreme elation by father Increases sense of self-esteem Three stage role development process Expectations + reality Transition to mastery Bonding Verses Attachment: Bonding – close emotional attraction to a newborn by the parents that develops the first 30-60 minutes after birth Unidirectional, from parent to infant Attachment- development of a strong affection between an infant and a significant other (mother, father, sibling, caregiver) Maternal Psychological Adaptation: Reva Rubin’s Three Phases Taking-in Phase: Time immediately after birth when the client needs others to meet her needs and relives the birth process with everyone Talkinghold Phase: second phase characterized by dependent and independent maternal behavior Letting-go Phase : third phase in which woman reestablishes relationships with others Postpartum Changes in the mother: Immediately after delivery, the mother experiences multiple physiological changes It is important for the nurse to assess all body systems and not just focus on the reproductive system changes Data collection is good time to teach the new mother on normal changes versus those that require reporting to her health care provider Screening Tools and Follow-up Care: PHQ9 Intimate partner violence (IPV) Screening Assess maternal blood type, if mom is Rh- and baby Rh+ order postpartum rhogam work up (administer within 72 hours) Flu vaccine Covid vaccine Tdap vaccine Rubella immune/equivocal/negative Mom’s choice for contraception at discharge Treatment plan- guided by severity, early recognition, support groups, therapy, ECT, combo therapy, medications: SSRI Postpartum Mood Disorders: Baby blues: mild depressive symptoms, anxiety, irritability, mood swings, tearfulness, increase sensitivity, fatigue Usually peaks at day 4 or 5 and resolves by day 10 Impact woman, newborn, and family 10-15% of women suffer from a mental health disorder Baby blues (mild PPD) affects 50-75% of PP women during first few weeks after delivery 6% of women develop depression for the first time during pregnancy Anxiety disorders Mood disorders Major depression Pregnancy-related mood disorders Postpartum depression and psychosis : symptoms last longer and are more severe – require treatment, may lead to poor infant bonding, alienation from loved ones, daily dysfunction, and violent thoughts/actions PPD occurs in 10-20% of PP women Also at risk: unexpected C/S, hysterectomy, fetal/neonatal loss, postpartum hemorrhage, or other complication Symptoms: intense sadness, labile mood swings, intense fear, anger, anxiety, unable to care for self, irritability, rejection of infant, obsessive dangerous thoughts Postpartum Mood and Anxiety Disorders: Postpartum psychosis Hallucinations, delusions, agitation, inability to sleep, bizarre, or irrational behavior Bipolar II disorder Major depressive episodes with recurrent hypomania Postpartum depression Postpartum-onset panic disorders Postpartum obsessive-compulsive disorder Postpartum traumatic stress disorder after childbirth Immediate Medical and Nursing Interventions to Correct Hypovolemia: Stop the blood flow Giving intravenous (IV) fluids to maintain the circulating volume and to replace fluids Give blood transfusions to replace lost erythrocytes Give oxygen to increase the saturation of remaining blood cells; a pulse oximeter is used to assess oxygen saturation of the blood Place an indwelling foley catheter to assess urine output, which reflects kidney function Hematomas of the Reproductive Tract: Collection of blood within tissue Birth trauma, usually on vulva or inside vagina If seen, looks like bulging bluish or purplish mass Unrelenting pain unrelieved by analgesics May complain of pressure in vulva, pelvis, or rectum Will not have unusual amounts of lochia Spinal Headache: Post dural puncture headaches (PDPHs) are headaches that occur when cerebrospin al fluid leaks into the epidural space through a tear in the dura. The tear is usually caused by a lumbar puncture or epidural Unintentional dural puncture occurs in 1-6% of epidural placements Headache worse when sitting or standing Accompanied by: neck stiffness, photophobia, nausea, low back pain, vertigo, subjective hearing symptoms Most resolve within 1 week Treatment if symptoms persist for 24-48 hours Headache associated with preeclampsia should be considered – check labs and blood pressure Spinal Headache Treatment Recovery: Mild symptoms: abdominal binder, bedrest, fluids, stool softener, caffeine, antiemetics, analgesics Severe symptom: epidural blood patch Nursing interventions: Supine position for 1-2 hours immediately after procedure (max. height 30 degrees) – helps maintain optimal intracranial pressure, helps blood to create a seal Obtain vital signs – every 15 min x 4, every 30 min x 2 Assess neurologic function: wiggle toes, lower extremity sensation Assess puncture site- bleeding, edema, hematoma, localized pain Pain assessment – analgesic as needed and prescribed Monitor for signs of adverse reactions – tachycardia, pallor, clammy skin Complications- meningitis, epidural abscess, seizures, bleeding into spinal canal Complications of Breastfeeding: Engorgement – continue frequent feeding, warm compress prior to feeding, express milk, ice after feeding, well-fitting bra, no wire Sore or cracked nipples – assess latch, rotate sides, frequent feedings, massage, warm compress before feeding Block ducts – can be from overabundant milk supply, often preventable, not emptying breast, not rotating positions constriction from bra Mastitis – breast inflammation that can cause pain, swelling, redness, and warmt. Most common in breastfeeding women, but it can also occur in other people. Symptoms: redness, swelling, and pain in one or both breasts Hard lumps Red marks Fever and general body aches Flu-like symptoms Engorgement Causes: clogged milk ducts, breaks in the skin of the nipple, hyperlactation, or an oversupply of milk Nipple damage Long gaps between feeds Stopping breastfeeding suddenly Tight or underwire bras Treatment: Antibiotics, emptying the milk from the breast, putting ice on the breast, and getting rest and plenty of fluids Prevention: breastfeed frequently, offer both breasts for each feed, express just enough milk for comfort, and check the breast shield size of your breast pump Teaching Topics for Postpartum Period: Pain and discomfort Immunizations Nutrition Activity and exercise Lactation Discharge teaching Sexuality and contraception Follow-up Ovulation and Return of Menstruation: Interplay of hormones: estrogen, progesterone, prolactin, and oxytocin Nonlactating women: return of menstruation 7-9 weeks after birth Lactating women: return dependent on breast-feeding frequency and duration: anywhere from 2 to 18 months Intervention – Criteria for Discharge Afebrile with pulse and respirations of normal rate and quality Blood pressure is within normal range for the patient Amount and color of lochia are appropriate for the duration of recovery Uterine fundus is firm Urinary output is adequate, voids without difficulty, if not voiding without difficulty, she demonstrates selfcatheritization and or care of urinary catheter Any surgical repair or wound has minimal edema and no evidence of infection and appears to be healing without complications Ambulates without difficulty and has adequate pain control Eats and drinks without difficulty Labs are reviewed and addressed by provider as appropriate Providing immunizations ABO blood group and Rh are known, Rhogam has been given if indicated Rubella status has been determined, and vaccine has been administered if indicated, unless patient declines Ensuring follow-up care: outpatient, telephone, home visit Nursing Management of the Neonate: