OB EXAM 2 Notes PDF

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ob maternity labor/delivery exam 2 notes ...

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MATERNITY EXAM 2 STUDY NOTES TOPIC

TEXTBOOK

ATI

Postpartum Adaptations

15

17

Nursing Management During the Postpartum Period

16

18-19

Nursing Management of the Postpartum Woman at Risk

22

20-22

Nursing Management of Pregnancy at Risk: Pregnancy Related Conditions

19

7-8, 10

Nursing Management of Pregnancy at Risk: Selected Health Conditions & Vulnerable Populations

20

15,16

Nursing Management of Labor and Birth at Risk

21

9

CHAPTER 15: POSTPARTUM ADAPTATIONS ● Puerperium: period after delivery of placenta, lasting for 6 weeks

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Some believe that it lasts well into the first year, making the fourth phase of labor the longest May last between 9 and 12 months as the mother works to lose weight & adjusts Reproductive System Adaptations Uterus Changes weighs approx 1,000g (2.2 lb) soon after birth 1 week after birth: shrinks in size by 50% & weighs about 500 g (1 lb) 6 weeks after birth: weighs approximately 60 g (2 oz) (prepregnancy weight) The uterus returns to its normal size via involution, which involves 3 retrogressive processes: (1) Contraction of muscle fibers to reduce previously stretched from pregnancy (2) Catabolism, which shrinks enlarged, individual myometrial cells (3) Regeneration of uterine epithelium from lower layer of decidua after upper layers have been sloughed off & shed during lochial d/c Uterus descends from level of umbilicus at rate of 1 cm per day. By 3 days, the fundus lies 2-3 fingerbreadths below umbilicus (slightly higher in multiparous women) By end of 10 days: fundus cannot be palpated since it descended into true pelvis Subinvolution: responsive to early dx & treatment Factors that facilitate involution: complete expulsion of amniotic membranes and placenta; Complication free delivery; breastfeeding mom; early ambulation Factors that stop involution: prolonged L&D; incomplete expulsion of amniotic membranes and placenta; uterine infection; overdistention of uterine muscles (e.g. multiple gestation, hydramnios, large singleton fetus); full bladder; anesthesia relaxes uterine muscles; close child birth spacing Lochia: vaginal d/c after birth; results from involution. Continues 4-8 wks Superficial layer of decidua basalis becomes necrotic and is sloughed off. roughly equal to the amount occurring during a heavy menstrual period (8-9 oz) Cesarean section: less bleeding because the uterine debris manually removed Foul odor = may indicate infection. Danger signs: bright red after lochia rubra has stopped & clots THREE STAGES OF LOCHIA (SHOULD HAPPEN IN ORDER)

Rubra

first 3 to 4 days after birth

deep-red mixture of mucus, tissue debris, & blood. As uterine bleeding subsides, it becomes paler & more serous

Serosa

3 to 10 days postpartum

pinkish brown in color; leukocytes, decidua tissue, red blood cells, & serous fluid

Alba

10 to 14 days postpartum but can last 3 to 6 weeks postpartum

creamy white or light brown d/c & consists of leukocytes, decidual tissue, & reduced fluid content.

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Afterpains: painful uterine contractions; more acute in multiparous & breastfeeding women. Breastfeeding and exogenous oxytocin administration cause painful uterine contractions due to oxytocin released by sucking reflex. Cervix: closure by 6 weeks & now appearing as jagged slit-like opening. Will never

regain pre-pregnancy appearance. Postpartum: shapeless and edematous; easily distensible for several days. Internal cervical os returns to normal in 2 wks meanwhile external cervical os never returns to normal ● Vagina: gradual thickening & return of rugae (in approx. 3 weeks). - Postpartum: returns to pre-pregnant size by 6-8 wks. Dyspareunia. Use water soluble lubricants for comfortable sex ● Ovarian function: returns & estrogen production resume ● Perineum: edematous & bruised. If episiotomy or laceration, complete healing may take 4 to 6 months in the absence of complications. - Hemorrhoids can happen. Ice packs, pour warm water over area; witch hazel pads; anesthetic sprays; sitz baths - Practice pelvic floor muscle training exercises to improve pelvic floor time, strengthen perineal muscles, and promote healing. If not done, then incontinence! Cardiovascular System Adaptations ● Blood volume ↓; returns normal within 4 wks postpartum ● Cardiac output ↓ 1-2 days postpartum & falls fast next 2 wks, then returns to non-pregnant levels within 6-8 wks ↑ ● HCT stable; acute decrease indicates hemorrhage ● Pulse rate (40-60 bpm first two weeks) - Tachycardic: may indicate hypovolemia, dehydration, hemorrhage ● BP ↓ first 2 days, then increase to pre-pregnancy value 3-7 days after childbirth; returns to normal by 6 wks - Increased BP & headache -> preeclampsia ● Elevated BP, cardiac output, and tachycardia indicates hemorrhage ● Coagulation factors remain ↑ during early postpartum period 2-3 wks. Risk for thromboembolism in lower extremities & lungs ● RBC decreases Day 1, then rise slowly in next 2 wks. ● WBC remains elevated for 4-6 days; then falls to 6,000-10,000/ mm3 Urinary System Adaptations ● 6 wks postpartum: GFR & renal plasma flow return to normal ● Voiding sensation may be affected ● Urinary atony: allows excessive bleeding. Often caused by urinary retention. - Frequent voiding of small amounts (< 150 mL) suggests urinary retention ● Hematomas: bladder tone r/t to regional anesthesia ● Diuresis r/t large amounts of IV fluids; decreasing antidiuretic oxytocin effect; build up & retention of extra fluids; decreasing production of aldosterone. - Begins within 12 hrs of birth & continues for 1 wk. Normal function resumes in 1 mo -

GI System Adaptations ● The GI system quickly returns to normal: relief of pressure on organs ● Decreased bowel tones for several days & decreased peristalsis r/t analgesic response; sx; diminished abd pressure; low-fiber diet; insufficient fluid intake; diminished muscle tone

● Women w/ hemorrhoids, perineal laceration, or episiotomy may fear pooping due to pain - Stool softener helps Musculoskeletal System Adaptations ● Joints return to prepregnant state except for feet ● 6 wks postpartum: joints completely stabilized & return to normal ● Diastasis recti: loss in muscle tone and separation of rectus abdominis muscle of the abdomen. If rectus muscle tone is not regained via exercise, inadequate support may suffice during future pregnancies. Integumentary System Adaptations ● Hair loss: first 3 mo PP, when estrogen returns to normal. Returns 4-15 mo ● Pigmentation fades. Stretch marks fade to silvery lines ● Diaphoresis is common for about a week postpartum for 1 wk; common during night Respiratory System Adaptations ● RR rate usually remains within the normal range; 16 to 24 breaths per minute ● Anatomic changes in thoracic cavity resolve quickly ● 1-3 wks postpartum: tidal volume, minute volume, vital capacity, and functional residual capacity return to prepregnant values Endocrine System Adaptations ● Placental hormones, estrogen and progesterone levels drop quickly. - Estrogen at its lowest 1 wk postpartum ● Engorgement: decreased estrogen & diuresis of excess extracellular fluids. - Prolactin levels remain elevated for breastfeeding mothers and decline within 2 weeks if not breastfeeding - Estrogen levels begin to increase by 2 wks postpartum for non breastfed women - 3 days postpartum: progesterone levels go undetected & production reestablished w/ first menses (anovulatory) - Lactating mothers resume their cycle 7-9 weeks PP Lactation ● Secretion of milk by the breasts via interaction of progesterone, estrogen, prolactin, and oxytocin. Typically appears 4 to 5 days after childbirth ● AAP recommends exclusive breastfeeding for 6 mo, followed by introduction of appropriate foods & continued breastfeeding to 1 yr. ● Prolactin (released from anterior pituitary gland) stimulate glandular cells to secrete milk ● Oxytocin released from posterior pituitary gland & initiates milk let-down ● “Breast crawl”: initiates breastfeeding ASAP after childbirth. Newborn skin to skin on mom’s trunk after birth, moves toward breast for self-attaching. - 2 days postpartum: soft & non tender breasts w/ tingling sensation “let-down reflex” ● If breastfeeding: frequent emptying, warm showers & compresses before feeding, cold compresses between feedings. - In order to maintain milk supply, breasts need to be stimulated by a nursing infant, a breast pump, or manual expression of the milk. ● If not breastfeeding: tight supportive bra; Ice, 15 to 20 minutes every other hour; Avoidance of breast stimulation ● Ovulation may occur before menstruation, therefore breastfeeding is unreliable method

of contraception unless mother breastfeeds. Self-Care Measures ● Afterpains are usually stronger during breast-feeding because oxytocin released by the sucking reflex strengthens the contractions. Mild analgesics can reduce this discomfort. ● Failure to maintain and restore perineal muscular tone leads to urinary incontinence later in life for many women. ● If rectus muscle tone is not regained through exercise, support may not be adequate during future pregnancies. Multicultural Family ● Somali women highly regarded for their mother role. Stay at home and refrain from sexual activity for 40 days. Then, mother and infant leave their home. Majority of Somali and Arab women breastfeed for extended periods of time ● Vietnamese women view PP as cold state. Warm food & environment. ● Chinese women: maintenance of body warmth to restore yin and yang. ● Western practices use cold packs or sitz baths to reduce pain. ● Hot-cold beliefs common among Latinos, Asians, and Africans. Psychological Changes ● Within 15 min of holding newborn, men experience raised levels of oxytocin, cortisol, and prolactin. ● Attachment: formation of a relationship between a parent and his or her newborn through a process of physical and emotional interactions Postpartum Mood Disorders ● 85% new mothers suffer from short lived postpartum “baby blues” characterized by: mild depression anxiety irritability, mood swings, tearfulness, increased sensitivity, fatigue - Usually peak at days 4 and 5 and resolve by day 10 ● Postpartum depression and psychosis - Symptoms last longer and are more severe and require treatment - May lead to poor bonding, alienation from loved ones; dysfunction, and violent thoughts PHASES OF MATERNAL ADAPTATION TO PARENTHOOD: RUBIN (1960) Taking-in phase

1-2 days

time immediately after birth when client needs sleep; depends on others to meet her needs; & relives the events of the birth process

Taking-hold phase

2 days- several weeks

dependent & independent maternal behavior

Letting-go phase

woman reestablishes relationships with other people, accepts reality

Variables Affecting Maternal Role Attainment ● Maternal: confidence, age, relationship with father, socioeconomic status, birth experience, stress, support system, personality traits, self-concept, child-rearing 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 (1) Commitment, attachment to unborn baby, preparation for delivery & motherhood (2) Acquaintance/attachment to infant, learning to care for infant, & physical restoration 2

to 6 weeks post birth (3) Moving toward a new normal (4) Achievement of a maternal identity through redefining self to incorporate motherhood (around 4 months) Engrossment: Characterized by 7 behaviors: (1) Visual awareness of the newborn (2) Tactile awareness of the newborn (3) Perception of the newborn as perfect (4) Strong attraction to the newborn (5) Awareness of distinct features of the newborn (6) Extreme elation by the father (7) Increased sense of self-esteem ● Three-Stage Role Development Process (1) Expectations: preconceptions about what home life will be like with a newborn. (2) Reality: occurs when father realizes that their expectations in phase one are not realistic (3) Transition to mastery: the father makes a conscious decision to take control and be at the center of his newborn’s life regardless of his preparedness

CHAPTER 16: Nursing Management During the Postpartum Period Typical Assessments in Postpartum Period ● During the first hours: every 15 minutes ● During the second hour: every 30 minutes ● During the first 24 hours: every 4 hours ● After 24 hours: every 8 hours Vital Signs Assessment ● Temperature: slight elevation during first 24 hours; normal afterward ● Pulse: 40 to 80 bpm; puerperal (postpartum period) bradycardia ● Respirations: 16 to 20 breaths per minute

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Blood pressure: within usual range Pain: goal between 0 and 2 on pain scale

RISK FACTORS FOR POSTPARTUM INFECTION ● ● ● ● ● ● ● ● ●

Operative procedure (forceps, c-section, vacuum extraction) Hx of diabetes (e.g. gestational onset diabetes) Prolonged labor (> 24 hrs) Use of indwelling urinary catheter Anemia (hemoglobin < 10.5 mg/dL) Multiple vaginal exams during labor Prolonged rupture of membranes (>24 hrs) Manual extraction of placenta Compromised immune system (HIV+)

RISK FACTORS FOR POSTPARTUM HEMORRHAGE ● ● ● ● ● ● ● ● ●

Precipitous labor (< 3 hours) (e.g. in the car) Uterine atony Placenta previa or abruptio placenta Labor induction or augmentation Operative procedures (vacuum extraction, forceps, cesarean birth) Retained placental fragments Prolonged third stage of labor (more than 30 minutes) Multiparity, more than three births closely spaced Uterine overdistension

Danger Signs ● Fever more than 100.4°F (38°C) ● Foul-smelling lochia or an unexpected change in color or amount ● Large blood clots, or bleeding that saturates a peripad in 1 hour ● Severe headaches or blurred vision (preeclampsia) ● 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 ● Shortness of breath or difficulty breathing without exertion ● Depression or extreme mood swings Physical Assessment: Postpartum Period - BUBBLE-EE ● 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 & Emotional status Breasts ● Check the nipples for cracks, redness, fissures, or bleeding. - Cracked blistered bruised or bleeding nipples in breastfeeding women indicate baby is improperly positioned on breast. - Palpate the breasts lightly to ascertain if they are soft, filling, or engorged, & document your findings. ● If not breastfeeding, use a gentle, light touch to avoid breast stimulation ● Assess for colostrum (creamy yellow) or foremilk (bluish white) ● Breast engorgement usually occurs during the first week postpartum. Common response to the sudden change in hormones & the presence of an increased amount of milk. As milk is coming in, breasts become firmer, “filling.” Engorged breasts are hard, tender, & taut.

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In breastfeeding women: encourage frequent feedings, at least every 2 to 3 hours. In bottle-feeding women: engorgement disappears as increasing estrogen levels suppress milk formation. Encourage the woman to use ice packs, wear a supportive bra 24 hours a day, & to take mild analgesics such as acetaminophen. Should avoid any stimulation to the breasts that might foster milk production, such as warm showers or pumping or massaging the breasts.

Uterus ● Empty bladder & auscultate bowel sounds prior to palpation using two-handed approach to stabilize & prevent uterine inversion. Fundus should be midline & should feel firm. ● Place your index finger on the fundus & count the number of fingerbreadths between the fundus & the umbilicus (1 fingerbreadth = 1 cm). - 1-2 hrs postpartum: fundus typically between umbilicus & symphysis pubis. - 6-12 hrs postpartum: fundus usually at the level of the umbilicus. - Fundus progresses downward at a rate of one fingerbreadth (1 cm) per day. - Should be nonpalpable 10-14 days postpartum Bladder ● Considerable diuresis—as much as 3,000 mL/day—may follow for several days after childbirth, decreasing by the 3rd day. Single voiding can be 500 mL. ● Assess the bladder for distention & adequate emptying. - Full bladder: dull to percussion & lochia drainage will be excessive. Palpate the area over the symphysis pubis. ● A full bladder tends to displace the uterus up and to the right Bowels ● Bowel elimination normal patterns return a week after birth. ● Bowel sounds are present in all four quadrants. Ask the woman if she has had a bowel movement or has passed gas since giving birth. Listen 2-3 minutes in each quadrant. ● Constipation is common. Normal assessment findings are active bowel sounds, passing gas, & a nondistended abdomen.

Lochia ● Lochia flow will increase when woman gets out of bed & when she breastfeeds. Bleeding too much if saturates a peri-pad within 30-60 mins. ● 3 stages: rubra -> serosa -> alba ● Amount of lochia: - Scant: 1-2-inch stain (10 mL loss) - Light or small: approx. 4-inch stain (10-25 mL loss) - Moderate: 4-6-inch stain (25-50 mL loss) - Large or heavy: pad is saturated within 1 hour after changing it ● Women who had c-section will have less lochia d/c than those who had a vaginal birth. ● Instruct frequent changing of perineal pads, continued use of peribottle, & hand hygiene Episiotomy & Perineum & Epidural Site ● Assess episiotomy & any lacerations at least every 8 hrs. Normal site should not have

redness, d/c, or edema. Most healing takes place within the first 2 weeks, may take 4 to 6 months for complete healing ● White line, swelling or discharge of episiotomy indicates discharge ● Severe, pain, perineal discoloration, & ecchymosis indicate a perineal hematoma ● Classification of Lacerations: - First-degree laceration: involves only skin & superficial structures above muscle - Second-degree laceration: extends through perineal muscles - Third-degree laceration: extends through the anal sphincter muscle - Fourth-degree laceration: continues through anterior rectal wall Extremities ● State of hypercoagulability during pregnancy protects the mother against excessive blood loss during childbirth & placental separation. ● 3 factors predispose women to thromboembolic disorders during pregnancy: stasis, altered coagulation (state of pregnancy), & localized vascular damage (may occur during birthing process). ● Risk factors for PE: anemia, DM, smoking, obesity, PIH, HTN, severe varicose veins, Pregnancy, OCs, C/S, severe infection, hx thromboembolic ds, multiparity,immobility >4 days, AMA > 35 y/o ● Accurate dx of PE necessary because it requires: prolonged therapy, 9 months of heparin during pregnancy, and prophylaxis during future pregnancies, and avoidance of oral contraceptive pills. ● Report lower extremity tightness or aching when ambulating that is relieved with rest & elevation of the leg. Edema in the affected leg (typically the left), along with warmth & tenderness, may also be noted. ● Women with an increased risk should wear anti embolic stockings or sequential compression devices ●

Psychosocial Development ● Bonding and Attachment - Native American mothers handle their newborns less often & use cradle boards. - Native American & Asian mothers delay breastfeeding until their milk comes in because colostrum is considered harmful for baby - Bonding: close emotional attraction to a newborn by the parents that develops the first 30 to 60 minutes after birth. Unidirectional, from parent to infant - Attachment: development of a strong affection between an infant and a signific...