Exam 2, semester 2

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What are the factors affecting labor?
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Terms in this set (284)
What are the factors affecting labor?
Powers: contracting and pushing efforts
Passage: maternal pelvis and soft tissues
Passenger: fetus, placenta, and membranes
Psyche: psychological elements
What hapens during the first stage of labor?
Uterine contractions begin, primary force moves the fetus through the uterus.
What happens during the second stage of labor?
Voluntary maternal pushing efforts with the force of contactions propel the fetus through the pelvis
What do we do for a patient with a fractured coccyx?
Donut pillow, bed rest, PT
What is lightening?
Descent of the head into the true pelvis.
What does it mean if the fetus is at 0 station?
The fetus is at the narrowest section of the pelvis.
What does -2 station mean?
Head is not engaged
What does +2 station mean?
Head is engaged and moving down into the pelvis
Longitudinal lie
Long axis of the fetus is parallel to the mother (most common)
Transverse lie
Long axis of the fetus is perpendicular to the long axis of the mother. The fetus cannot be delivered vaginally
Fetal attitudeRelation of fetal body parts to each otherAttitude of flexionChin to chest. NormalCephalic presentationHead presenting firstBreechPresenting part is the buttock and /or feetTransversePresenting part is usually the shoulderCompoundFetus assumes a unique posture, usually with the arm or hand presenting alongside the presenting part.Fetal PositionLocation of the presenting part in relation to the 4 quadrants of the pelvisMalpresentationAll presentations other than vertex. Usually delivered by C sectionWhat factors influence a woman's psychological coping mechanisms?Culture, (need to be culturally aware) expectations, support systems, type of support during labor. Actively involve woman in her plan of care.How does anxiety affect labor?Anxiety can release adrenalin, which can slow labor progression. Studies show that a support person, ie spouse, friend, or nurse, can decrease anxiety, decreasing interventions, lower pain levels, and increased maternal satisfactionHow do we know if a woman is in false labor?Contractions are inconsistant, no change or decrease with activity. Often stop with ambulation. Braxton Hicks Abdomen and groin are uncomfortable. No cervical change.How do we know if a woman is in true labor?Progressive cervical changes. Dilation and effacement (Most important!) Contractions are consistant, and tend to increase with walking. Girdle-like discomfort, menstrual type cramps at start.When should a woman go to the birth center?When she has contractions, rupture of membranes, bleeding, decrease in fetal movement, intense painWhat type of pattern will we see in a true rupture of membranes?FerningHow is nitrazine paper used?If the membranes have ruptured, pH will be above 7.0. Basic pH may be urine.First stage of laborEffacement and dilation of cervix. Forces of uterine contractions begin the onset of labor. First stage ends when the cervix is 10 cm dilated, 100% effaced. Longest of the stagesName the 3 phases of the first stage of laborLatent-up to 3cm Active-4-7 cm Transition-8-10 cm (crabby! Epidural helps)Fetal assessmentFHR- Intermittent vs. Continuous external fetal monitoring. Amniotic fluid- spontaneous ROM vs assisted ROM Note color and odorEffacementLower third, thinning of the cervix. Goes from 0-100%DilationOpening of the cervix, widening. Goes from 0-10What happens with cord prolapse?Fetal heart rate dropsMaternal aassessmentVitals, T,P,R, BP-variable frequencies Contractions-palpations vs. Electronic fetal monitoring Labor progress- periodic vaginal exams I&O-bladder distention, rectal pressure Response to labor (mom and support person)When is the mom most receptive to teaching?Latent phaseWhat happens during the second stage of labor?Expulsion Forces- uterine contractions and pushing Begins 10cm dilated, 100% effaced Ends-birth of baby Duration- variableWhat is the key intervention for perineal swelling?Ice perineum for 24 hoursHow much blood volume does mom gain?1500mL increase in blood volume, also increases risk for DVTsWhat happens during the third stage of labor?Separation of placenta Forces-uterine contractions Begins-birth of baby End-expulsion of placenta Duration5-30 min. 2 sides "shiny schultz"- fetal "Dirty duncan" maternalWhat happens in the fourth stage of labor?Physical recovery- bonding Forces-uterine contractions Begins-delivery of placenta Ends-1-4 hrs aftee delivery Duration-variableWhat does Fetal heart rate reflect?OxygenationWhat are the 3 critical elements of adeqate fetal oxygenation?Mom Placenta Fetus Adequate placental exchangeAdequate Uteroplacental exchangeHypertonic uterine contractions Duration, +60 sec Frequency >/= every 2 min Interval decreased rest period. Open exchange btwn placenta and fetusPlacental disruptionsKnot in cord, baby leaning on it.Nuchal cordUmbilical cord wrapped around baby's neck. Often resolves before birth. Usually not a big problem, if it is loose it can easily be unwrapped from the neck.Fetal response to placental circulationExchange occurs in intervillous spaces Spiral arteries supply intervillous spaces, compressed during contractionsWhen does most placental exchange occur?Between contractionsWhat is the function of placental reserve?Reserves oxygen available to the fetus to withstand the transient changes in blood flow and oxygen during laborWhat are the advantages and limitations of auscultation and palpation in fetal monitoring?Advantage- mobility Limitation- Not continuousWhat are the advantages and disadvantages of Electronic fetal monitoring?Advantage= More data/ Permanant record Limitation- Limits mobility, "High tech" atmosphereWhat do we Auscultate FHR for?Rhythm. Increase or decrease in FHR. Variability not possible to assess.External monitoring equipmentDoppler ultrasound transducer Tocodynamometer, Toco= labor Tocolysis= stop laborInternal monitoring equipmentScalp electrode- only used if they can't get an accurate reading externally. Intrauterine pressure catheterWhat is the normal range for fetal heart rate?110-160 Mean FHR rounded to increments of 5 BPM during a 10 min window.BradycardiaLess than 110 BPM for at least 10 min. Not enough O2TachycardiaGreater than 160 BPM for at least 10 min. Indicates infectionWhat causes early fetal decelerations?Fetal head compressionsWhat are some special considerations with pharm pain mgmt?Must consider both mom and fetus. Slows labor down Complications may limit choices Substance abusers must be medicated carefully Monitor pain scaleWhat is the primary side effect of opioid analgesia?Resp depression Must be timed carefullyWhat would we give as an antidote for opioid resp. depression?NarcanAdjunctive drugsAntiemetics, (reduce nausea) tranquilizers, sedatives, (anxiety) phenergan (sedation, n&v) vistaril (anxiety)SedativesBarbiturates NOT routine Extreme fatigueRegional pain control EpiduralLocal anesthetic injected into epidural spaceLocal anesthesiaAnesthesia in immediate area Episiotomy or repairSpinal (subarachnoid)Local anesthetic injected into subarachnoid space in a single doseWhat does the nurse do during an epidural?Check BP and FHR per policy Assess VS Lateral positioning Assess effectiveness Assess level of block Monitor for nausea Assess post procedure headache Assess for urinary retention Monitor UCs DON'T touch the uterine pump!General anesthesiaSystemic pain control Loss of consciousness Rarely used for vag birth C section use: emergencies, poor candidates for epidural, refusalWhat are adverse effects of anesthesia?Maternal aspiration Restrict PO intake Bicitra administration-antacid Respiratory depression Mom or infant - use Narcan More likely in infant Uterine relaxation Increased risk for PP. HemorrhageInduction and augmentation of labor. When is it done? What is it?Done after 39 weeks Use of artificial methods to stimulate uterine contractionsTechniques used to induce laborAmniotomy Medications ; prostaglandin, IV oxytocin (pitocin), bothRisks of inducing laborTachysystole, uterine rupture, (caused by overstimulatiin), maternal water intoxicationWhat precautions do we need to be aware of when using oxytocin?Powerful, unpredictable drug Dilute in IV IV piggyback, must be able to shut off quickly Slow start, (1-2 mu/min) gradual increase Always on an infusion pump. Electronic fetal monitorWhat would indicate that labor should be induced?Preeclampsia SROM Chorioamnionitis Maternal medical conditions IUGR, post term, maternal-fetal blood incompatability, gestational diabetes IUFD Fast laborsWhat are contraindications to inducing labor?Placenta previa Cord prolapse Malpresentation Active herpes(zovorax antiviral prevents outbreak) Pelvic structure abnormality Previous vertical CS scarFetal considerations for inductionMust have reassuring FHR prior to starting IOLNursing care for non reassuring FHR patterns or UCsReduce or stop oxytocin infusion Increase primary IV Left lateral position O2 at8-10L/min Notification May need terbutalineInterventions associated with inductionStrict I&O Watch bladder during epidural Fluid overload, water intoxication IV fluids Bed rest Increased pain med Epidural Amniotomy (break water) Prolonged stay in unitAmniotomyArtificial rupture of membranes Indications Labor induction Internal Electronic fetal monitor Risks Cord prolapse InfectionNursing care for amniotomyFHR assessment Assist with amniotomy Underpads Sterile gloves Sterile lubricantCare after amniotomySame as after SROM FHR at least 1 min (cord prolapse) Chart quantity, color, odor Temp Q 2 hours (infection) Promote comfortRisks of EpisiotomyInfection Perineal painNursing care for episiotomyObserve for hematoma Ice packWhat is dystocia?Long, diffuicult or abnormal laborWhat is the primary reason women have a first C section?DystociaFactors that influence labor, PowersThe powers are the pushing- contractionsThe passengerThe babyThe passageVagina/pelvisThe psycheAnxiety/stress/painWhat are hypertonic contractions?Excessively frequent, painful yet ineffective. Uterine tachysystole, more than 6 contractions in 10 min.What are normal contractions?2-3 min apart, last 30-45 secondsHypotonic contraction patternWeak, ineffective or absent Result in failure to efface and dilate cervix for progession of laborNursing actions for hypertonic contractionsProvide pain relief Hydrate with IV fluids Promote rest Assess FHR, UCs, and labor progress Emotional support Admin. Tocolytic (terbutaline) as orderedWhat is the goal for hypertonic contractions?Goal is to promote uterine rest and develop a normal pattern of UCs in the active phaseWhat is a woman and fetus having hypertonic contractions at risk for?Abruptio placenta and exhaustion, fetus is at risk for intolerance and asphyxiaWhat is bradycardiaHR in the 90s for 10 minNursing actions for hypotonic contractionsAssess uterine activity, maternal/fetal status Administer IV PO fluids Ambulate or change position Use therapeutic communication Anticipate amniotomy or administration of oxytocin Maintain aseptic technique Woman at risk for exhaustion and infectionPrecipitous laborLabor that lasts less than 3 hours from onset of regular contractions Contributing factors Hx of precipitous labor and multiparityWhat are the risks of precipitpous labor?Risk for uterine rupture, postpartum hemorrhage, cervical/vaginal lacerations, hematomaa Fetus at risk for hypoxia or CNS DepressionNursing actions for precipitous laborRemain in the room! Assess Elect. Fetal Monitor Tachysystole UCs occuring every 2 min and lasting >60 sec Abnormal FHR and rapid cervical dilation Prepare for delivery Be alert to verbal signs of impending birth (rectal pressure) Offer emotional support Anticipate postpartum and neonatal complications Don't encourage pushingInadequate expulsion of forcesInadequate or ineffective pushing in second stage of labor. Risk with epidural Woman at risk for exhaustion, episiotomy, C section, perineal trauma Fetus at risk for FHR changes and asphyxia Assist and encourage : open glottis pushing Position changes Rest periodsWhat is cephalopelvic disproportion?Baby's head too big to fit through mom's pelvis Usually diagnosed in labor C section often neededWhat does the success of labor depend upon?Fetal size, presentation and position (passenger) Size and shape of mom's pelvis (passage) Quality of uterine contractions (power of labor)What are nursing interventions for intrauterine infection?Limit vaginal exams Change wet underpads freq Perform perineal care Monitor FHR and mom's VS q 2 hrs Observe amniotic fluidOperative vaginal deliveryVaginal birth with assist of forceps or vaccum extracction Facilitates birth and shortens second stage of labor. C section performed if unsuccessful Strict guidelines must be followedMaternal risks for operative vaginal deliveryVaginal aand cervical lacerations Hemorrhage Bladder trauma Extension of episiotomy Perineal hematoma Perineal wound infectionVaginal birth after cesareanCandidates have had one or two previous c sections with a low transverse incision and adequate pelvis. Vertical incisions more likely to rupture.When is VBAC contraindicated?Previous vertical incision Hx of uterine rupture Pelvic abnormalities Inability to perform emergency c section VBAC rates decreased due to legal pressureWhat is post term pregnancy?Lasting longer than 42 weeks gestation Actual cause unclear Lowered incidence with use of first trimester u/sWhat are risks of post term pregnancy?Cord accident due to increased amniotic fluid Decreased placental reserve due to decreased amniotic fluid Fetal macrosomiaNursing actions to anticipate with post term preg.Induction of labor Cervical ripening agents(cervidil)Shoulder dystociaDifficulty delivering the shoulders after the head "Turtle sign" head retracts May lead to prolonged delivery time >60 sec Fetal mortality / morbidity Macrosomia, maternal diabetes,excessive weight gain, post date preg.Nursing actions for shoulder dystociaAnticipate extension of epesiotomy McRoberts maneuver, sharply flexing legs toward maternal abdomen to straighten sacrum Woods corkscrew maneuver Maneuvers usually work, if not, emerg. C sectionProlapsed umbilical cordCord lies below presenting part of the fetus If it occurs it is usually with AROM or SROM FHR bradycardiaRisk factors with prolapsed umbilical cordFetus remains at a high station Small fetus that fits poorly in the pelvic inlet Malpresentation (breech) Polyhydraminos (increased fluid) Not always visibleNursing actions for prolapsed cordRelieve oressure on cord manually Change position (knee to chest or trendelenburg) Anticipate emerg c section O2 via facemask Iv fluid hydration bolus Admin tocolytic drugs as ordered Warm saline soaked towels applied to cord Address anxiety of womanWhat risks are associated with uterine rupture?Previous Hx of c sec or uterine surgery Multifetal gestation Uterine tachysystole Blunt abd traumaWhat are the clinical manifestations of uterine rupture?S/s of hypovolemic shock (decreased BP & pulse) Severe tearing sensation in abdomen Fetal distress Ascending station of fetal presenting part (baby moving back up) Maternal and fetal survival depends on prompt ID and emerg. C secWhat is an amniotic fluid embolism? AFEAmniotic fluid is drawn into maternal circulation and carried to her lungs Rare but often fatal Can occur during labor, birth, or 24 hrs after birth Due to high intrauterine pressure that draws fluid unto veinsClinical msnifestations of AFEChest pain. Dyspnea, cyanosis, tachycardia, hypotension, hemorrhage, cardiac-resp arrestCesarean section (c/s)Operative procedure in which the fetus is delivered through an incision in abd wall and uterus Approx 1/3 of couples experience c sec.How are the needs of a c sec different than vag birth?Longer hospital stay Longer recover time Increased pain More neg. Emotion re childbirth, esp if unplannedWhat re the indications for C section?Dystocia Previous c sec or uterine surgery Malpresentation Fetal intolerance of labor Placental abnormalities Uterine rupture Maternal health, diabetes, preeclampsiaWhy would a c section be planned/scheduled?Placenta previa, large baby, breech, CPDWhy would an emergency c section need to be done?Cord prolapse, lengthy labor, preeclempsiaWhat are the pre op nursing actions for c secMonitor VS for mom and fetus Verify NPO at least 6-8 hrs Admin IV fluid per orders Preload of 500-1000 mL Increase fluid vol, decrease hypotension r/t anesthesia Give antacids Review labs (Hct, Hgb, WBCs) Insert foley catheter Shave abd/ upper pubic reg Provide emotional support Don't forget sig otherWhat are contraindications for anesthesia?Refusal Low platelet count Maternal hypovolemia Increased intracranial pressureGeneral anesthesiaRarely used - risky Gastric aspiration leading to pneumonitisIndications for general anesthesiaPatient refuses regional anesthesia Rapid delivery is needed Severe hemorrhage Seizures Failed spinalWhat is a pfannestial incision?"Bikini cut", low transverse uterine incision. PreferredClassical cesareanRare, used in emergency, (baby comes out faster) vertical midline incision made in abd wall.Intraoperative nursing actionsDepends on assignment Assist woman onto operating table with rolled up blanket under right buttock Explain actions and offer emo support to couple Tell father where to sit and what he can/can't touch "Time out" 6 rightsWhat are compications of intraoperative birth? (Rare in healthy mom)Hemorrhage Bladder, uterus and bowel trauma Mom resp depression and hypotension Anesthesia in moms bloodstream Ear ringing Metallic taste HypotensionNursing actions for neonate during c secCheck equip/ supplies for newborn Apgar score at 1 and 5 min Record time of delivery of neonate and placenta Place ID bands on parents and baby Ensure mom touches baby before leaving roomPostoperative complications of c/sHemorrhage DVT Pulmonary embolism Paralytic ileus (no bowel movement) Hematuria- blood in cath bag, trauma to bladder InfectionPost op evaluation of anesthesiaAssess level of sensation Observe for side effects Hemorrhage r/t uterine atony Seizures Prolonged decreased sensation in legs Post dural puncture headaches Newborn resp depressionPost op nursing interventions after c/sVS Assess fundus and lochia Assess abd dressing Monitor for hemorrhage and infection Assess pain Monitor urinary output via foley cath Monitor IV fluids and meds as ordered Monitor level of anesthesia Assist with breastfeeding Encourage coughing and deep breathing Apply compression devices to LE Splint abd when repositioning Monitor for return of sensation in LE Dangle at bedside, monitor for dizziness Assist with ambulationHow do you palpate for uterine tone?Palpate for location, position and tone at level according to postpartum day Should be midline Should be firmInterventions for abnormal assessment findingsDisplaced fundus Assess bladder for fullness Encourage voiding or straight cath per order Reassess fundus for positionWhat do you do for a boggy fundus?Massage with palm Admin oxytocin/ methergine/hemabate as ordered Have baby breast feed if mom's plan Reassess fundus for firmnessWhat are some physiological changes after delivery?Afterpains increase in overdistended uterus May be more severe in multiparus womanHow does the lochia evolve?Rubra, ted, 3 days (blood) Serosa pink, 4-10 days (serous, exudate, RBC's, WBCs) Alba, white, epithelial cellsWhen willmenstruation resume?May resume in 6-10 weeks if not breastfeeding If breastfeeding, depends on length and amt. (Due to elevated serum prolactin levelsMaternal risks for operative vaginal deliveryVaginal aand cervical lacerations Hemorrhage Bladder trauma Extension of episiotomy Perineal hematoma Perineal wound infectionVaginal birth after cesareanCandidates have had one or two previous c sections with a low transverse incision and adequate pelvis. Vertical incisions more likely to rupture.When is VBAC contraindicated?Previous vertical incision Hx of uterine rupture Pelvic abnormalities Inability to perform emergency c section VBAC rates decreased due to legal pressureWhat is post term pregnancy?Lasting longer than 42 weeks gestation Actual cause unclear Lowered incidence with use of first trimester u/sWhat are risks of post term pregnancy?Cord accident due to increased amniotic fluid Decreased placental reserve due to decreased amniotic fluid Fetal macrosomiaNursing actions to anticipate with post term preg.Induction of labor Cervical ripening agents(cervidil)Shoulder dystociaDifficulty delivering the shoulders after the head "Turtle sign" head retracts May lead to prolonged delivery time >60 sec Fetal mortality / morbidity Macrosomia, maternal diabetes,excessive weight gain, post date preg.Nursing actions for shoulder dystociaAnticipate extension of epesiotomy McRoberts maneuver, sharply flexing legs toward maternal abdomen to straighten sacrum Woods corkscrew maneuver Maneuvers usually work, if not, emerg. C sectionProlapsed umbilical cordCord lies below presenting part of the fetus If it occurs it is usually with AROM or SROM FHR bradycardiaRisk factors with prolapsed umbilical cordFetus remains at a high station Small fetus that fits poorly in the pelvic inlet Malpresentation (breech) Polyhydraminos (increased fluid) Not always visibleNursing actions for prolapsed cordRelieve oressure on cord manually Change position (knee to chest or trendelenburg) Anticipate emerg c section O2 via facemask Iv fluid hydration bolus Admin tocolytic drugs as ordered Warm saline soaked towels applied to cord Address anxiety of womanWhat risks are associated with uterine rupture?Previous Hx of c sec or uterine surgery Multifetal gestation Uterine tachysystole Blunt abd traumaWhat are the clinical manifestations of uterine rupture?S/s of hypovolemic shock (decreased BP & pulse) Severe tearing sensation in abdomen Fetal distress Ascending station of fetal presenting part (baby moving back up) Maternal and fetal survival depends on prompt ID and emerg. C secWhat is an amniotic fluid embolism? AFEAmniotic fluid is drawn into maternal circulation and carried to her lungs Rare but often fatal Can occur during labor, birth, or 24 hrs after birth Due to high intrauterine pressure that draws fluid unto veinsClinical msnifestations of AFEChest pain. Dyspnea, cyanosis, tachycardia, hypotension, hemorrhage, cardiac-resp arrestCesarean section (c/s)Operative procedure in which the fetus is delivered through an incision in abd wall and uterus Approx 1/3 of couples experience c sec.How are the needs of a c sec different than vag birth?Longer hospital stay Longer recover time Increased pain More neg. Emotion re childbirth, esp if unplannedWhat re the indications for C section?Dystocia Previous c sec or uterine surgery Malpresentation Fetal intolerance of labor Placental abnormalities Uterine rupture Maternal health, diabetes, preeclampsiaWhy would a c section be planned/scheduled?Placenta previa, large baby, breech, CPDWhy would an emergency c section need to be done?Cord prolapse, lengthy labor, preeclempsiaWhat are the pre op nursing actions for c secMonitor VS for mom and fetus Verify NPO at least 6-8 hrs Admin IV fluid per orders Preload of 500-1000 mL Increase fluid vol, decrease hypotension r/t anesthesia Give antacids Review labs (Hct, Hgb, WBCs) Insert foley catheter Shave abd/ upper pubic reg Provide emotional support Don't forget sig otherWhat are contraindications for anesthesia?Refusal Low platelet count Maternal hypovolemia Increased intracranial pressureGeneral anesthesiaRarely used - risky Gastric aspiration leading to pneumonitisIndications for general anesthesiaPatient refuses regional anesthesia Rapid delivery is needed Severe hemorrhage Seizures Failed spinalWhat is a pfannestial incision?"Bikini cut", low transverse uterine incision. PreferredClassical cesareanRare, used in emergency, (baby comes out faster) vertical midline incision made in abd wall.Intraoperative nursing actionsDepends on assignment Assist woman onto operating table with rolled up blanket under right buttock Explain actions and offer emo support to couple Tell father where to sit and what he can/can't touch "Time out" 6 rightsWhat are compications of intraoperative birth? (Rare in healthy mom)Hemorrhage Bladder, uterus and bowel trauma Mom resp depression and hypotension Anesthesia in moms bloodstream Ear ringing Metallic taste HypotensionNursing actions for neonate during c secCheck equip/ supplies for newborn Apgar score at 1 and 5 min Record time of delivery of neonate and placenta Place ID bands on parents and baby Ensure mom touches baby before leaving roomPostoperative complications of c/sHemorrhage DVT Pulmonary embolism Paralytic ileus (no bowel movement) Hematuria- blood in cath bag, trauma to bladder InfectionPost op evaluation of anesthesiaAssess level of sensation Observe for side effects Hemorrhage r/t uterine atony Seizures Prolonged decreased sensation in legs Post dural puncture headaches Newborn resp depressionPost op nursing interventions after c/sVS Assess fundus and lochia Assess abd dressing Monitor for hemorrhage and infection Assess pain Monitor urinary output via foley cath Monitor IV fluids and meds as ordered Monitor level of anesthesia Assist with breastfeeding Encourage coughing and deep breathing Apply compression devices to LE Splint abd when repositioning Monitor for return of sensation in LE Dangle at bedside, monitor for dizziness Assist with ambulationHow do you palpate for uterine tone?Palpate for location, position and tone at level according to postpartum day Should be midline Should be firmInterventions for abnormal assessment findingsDisplaced fundus Assess bladder for fullness Encourage voiding or straight cath per order Reassess fundus for positionWhat do you do for a boggy fundus?Massage with palm Admin oxytocin/ methergine/hemabate as ordered Have baby breast feed if mom's plan Reassess fundus for firmnessWhat are some physiological changes after delivery?Afterpains increase in overdistended uterus May be more severe in multiparus womanHow does the lochia evolve?Rubra, ted, 3 days (blood) Serosa pink, 4-10 days (serous, exudate, RBC's, WBCs) Alba, white, epithelial cellsWhen will menstruation resume?May resume in 6-10 weeks if not breastfeeding If breastfeeding, depends on length and amt. (Due to elevated serum prolactin levelsPhysiological changes to the vagina after birthCervix formless, flabby, open wide, edematous, vaginal walls edematous, few rugae. Perineal edema Trauma, episiotomy, lacerations, hemorrhoidsVaginal and perineal assessmentMild edema, minor ecchymosis, approximation of the edges of the epesiotomy or laceration, mild to moderate pain, while patient is in side lying position, assess for episiotomy/repair of laceration and hemorrhoidsBreast assessmentObserve for size, shape, symmetry, note dimpling or thickening. Insepect areola and nipples Palpate breasts, soft, nontender for first couple days. Colostrum first 24 hours, skim milk appearance In 72-96 hrs, monitor for milk coming in, breast lumpy/ nodular feeling "filling" Monitor for engorgement, 3rd or 4th dayPromoting breast comfortHandwashing, Well fitting bra for 2 wks 24/7 No soap on nipples If nipples are sore, dab with breast milk and air dry. Feed every 2-3 hrs. Empty breasts to prevent milk stasis/plugged milk ductsBreast care for non breastfeeding momAvoid breast stimulation, ie hot showers, do not pump, tight fitting bra, ice packs for comfortHow do you prevent plugged milk ducts?Frequent breastfeeding Empty breasts with each feeding Change infant's position Warm compress Massage breasts prior to feeding Supportive braWhat changes occur in the cardiovascular system after birth?Expect 400-500mL blood loss after vaginal birth, 1000mL with c/s Postpartum chills-vascular instability Cardiac output increases due to volume back to mom and lasts 48°, bradycardia (40-50 bpm) Plasma volume decreases, diuresis, (12-24° postpartum) Diaphoresis (occurs first few weeks postpartum)Blood lab values postpartumWBC count increases 25,000/ mm (returns to normal value in a week) Hgb decreases 1-1.5 g/dl, Hct decreases 3-4% per 500mL blood loss (returns to normal in 4-6 weeks) Clotting factors decrease gradually (fibrinogen returns to normal in 2 wks) risk for thrombosis formationWhat should we expect of vital signs postpartum?BP remains the same as predelivery Orthostatic hypotension (decrease 15-20mm/Hg) HR remains normal or decreases for 48° RR 12-20/min Temp increases 100.4℉ (38℃) for 1st 24 hrs, infection Incisional pain, contractions, headacheWhat interventions should a nurse implement to prevent orthostatic hyptension?Take VS before getting OOB for first time, compare to baseline Assess post delivery CBC if completed- compare to admission CBC Slow position change Sit at edge of bed before standing, stand in place marching to get bearings, ensure feeling in feet (epidural) stay close to bed Have help for first time OOB OOB to chair for first ambulation Leave call light in placeRubella vaccineIf mom is rubella nonimmune prenatally, give rubella vaccine before discharge, avoid pregnancy for 4wksTdap vaccineFor tetanus, diptheria, pertussisHepBAdmin if not immuneWhat is documented for vaccines?Manufacturer, lot#, Exp. Date. Give info to pt. RhoGam cardHow doesthe urinary system change after childbirth?Postpartal diuresis Bladder distention Incomplete emptying of bladder Inability to void Risk factors: regional anesthesia, edematous urethra, bladder fills from diuresis Can lead to infection and postpartum hemorrhageWhat do we assess the bladder for?Distention, palpate for bulge, monitor for displacement of the fundus Monitor urinary output: 300-400mL per void indicates empty bladderPromoting bladder eliminationEnsure adequate fluid intake Premed for peri pain Run water, mom's hands in water, pour water over vulva Void in shower or sitz bath Provide teaor choice of fluid Peppermint oil on cotton ball in hat Catheterize as ordered Teach kegelsWhat causes a risk for bowel constipation?Meds Epidural Iron supplements Dehydration Peri discomfort HemorrhoidsNursing interventions to promote bowel eliminationFluids, ambulation increases gastric motility, fiber, stool softeners, laxativesNutrition for a lactating mom after birthIncrease calorie intake by 500 cal per day Fluid intake of 2 L per day Avoid foods that cause problems for the infant(spicy, garlic, acidic)Nutrition for the nonlactating momIncrease protein and vitamin C for healing Encourage healthy foods Respect cultural preferencesLower Extremity assessmentMonitor CNS Check for varicose veins Monitor for s/s of thrombophlebitis: calf tenderness, redness, edema, warmth, muscle pain, swelling of veins Monitor pedal edema Encourage leg exercises and early ambulation Assess deep tendon reflexes (advanced practitioner) -1+ to 2+ WNL -3 to 4+ hyperactiveHow long is a typical hospital stay for an umcomplicated vaginal delivery?48 hrs, 2 nightsHow long is the hospital stay for a cesarean delivery?96 hrs, 3 nightsHow do we care for the c sec mom?IV therapy: initial IV with pitocin, followed by D5LR or LR-heploc-discontinue with good PO VS as ordered then q4 for first 24 hrs. Analgesics: morphine or dilaudid PCA, oral med after PCA discontinued Monitor lung sounds, I/S, turn, cough, deep breathe Monitor bowel sounds, flatus, abd assessment, abd incision/dressing Progession of diet:clear liquids as tolerated Removal of foley cath usually next day Activity level depends on type of anesthesia Interventions for possible nausea, vomiting, pruritis, urinary retention, and resp depressionWhen do I call the advanced practitioner?Excessive or foul smelling lochia Elevated temp Pelvic or abd tenderness Frequent voidings of >150mL and c/o urgency, frequency and dysuria Breasts tender, warm, reddened, cracked nipples (mastitis) Leg pain (phlebitis)Nursing actions to assist moms in transitionID factors contributing to delay in transition Assess maternal phases Taking in phase- teach in short, focused sessions Taking hold phase offer praise Provide comfort measures Kangaroo care:skin to skin contact, privacy Provide guidanceDescribe postpartum bluesMild depression that lasts no longer than a few weeks after birth (more than two weeks, or can't care for self and baby, seek help)What are nursing actions for postpartum blues?Provide info Explain that it is common Encourage rest periods Encourage partner to give emo and physical support Explain that if symptoms last more than two weeks, seek helpPostpartum hemorrhage (PPH)Early pph occurs in first 24 hrs with blood loss of >500 mLs vaginal, >1000 mLs c/s3 major causes of pphUterine atony-lack of muscle tone resulting in failure of the uterine muscle to contract after the placenta is expelled Lacerations HematomasManifestations of uterine atonySoft or boggy fundus Uterus loses tone after massage Fundus located above expected level Excessive lochia Tachycardia/hypotension 10% decrease in hematocrit from admission to need for transfusion, especially if symptomatic Cool, clammy, pale skinTherapeutic management of uterine atonyMassage fundus first Meds to cause uterine contractions: Pitocin, methergine, hemabate, misoprostol, (cytotec) Empty bladder if needed Replace intravascular fluid: isotonic-NS, or LR Blood products:RBCs, clotting factors Last resort: uterine packing Bimanual compression, ligation of uterine artery, hysterectomySigns and symptoms of lacerationsExcessive bright red bleeding with a firm fundus. Low BP, High HR May require surgical repair, suturesSigns and symptoms of perineal hematomaDeep, severe, unrelieved rectal pain and feelings of pressure. Hypotension and tachcardia with a firm fundus indicate developing hematomaTherapeutic management of peri hematomaSurgical excised and ligation of the bleeding blood vessel (penrose drain) IV fluids Blood productsLate postpartum hemorrhageOccurs after 24 hrsMost common causes of late postpartum hemorrhageSubinvolution-delayed return of the uterus to it's nonpregnant size and consistancy Retained placental fragments that remain attached to uterus forming clots. Clots will fall off causing hemorrhage HematomasLate post part HemorrhageBleeding should be less every day. If bleeding increases, report.What is subinvolution?Uterus does not decrease in size or descend into pelvisWhat are common causes of subinvolution?Retained placental fragments or pelvic inflammationSigns of subinvolutionProlonged discharge of lochia or irregular, excessive uterine bleeding, large, soft uterusSymptoms of subinvolutionPelvic pain or heaviness, backache, fatigue, andTherapeutic management of subinvolutionDilation and curettage (D&C), methergine, antibioticsNursing responsibilities for postpartum hemorrhageMaintain bedrest Admin IV fluids per Dr order Notify provider Teach fundal assessment and massage Review H&H levels, coagulation studies, PT/INR, PTT, platelets, fibrinogen, fibrin degredation products, bleeding time, type and crossmatch for blood products Encourage diet high in iron Blood products: RBCs, platelets, fresh frozen plasma, clotting factors if necessaryMost common thromboembolic disorders includeSuperficial venous thrombosis, deep vein thrombosis (DVT), pulmonary embolism (PE) Major cause of maternal death in US!3 major causes of thrombosis areVenous stasis Blood vessel injury Hypercoagulation:clotting factors and fibrinogen elevated in postpartum periodSymptoms of DVTLeg edema, erythema, heat, tenderness, pain with ambulation, chills, general malaise, stiffness of the affected leg, pale and cool to touch Diagnosed by ultrasound or MRIDVT preventionHeparin subcut during preg and after delivery Use of stirrups no longer than 1hr during labor Frequent ambulation, leg exercises TEDs SCDsTherapeutic management of DVTBedrest with leg elevated Antiembolism stockings as ordered Analgesic meds/moist heat as ordered. Anticoagulants as ordered Monitor Bloodwork for effectiveness, PTT, PT, INR Oral contraceptives contraindicated Educate to avoid another preg. Warfarin is teratogenicNursing care for DVTCheck pedal pulses Check LE for warmth and redness, or cyanosis and coolness, compare LE Assess pain Monitor resp status Monitor bleeding if on anticoagulants May breastfeedHow does a PE pulmonary embolism occur?Occurs when fragments of a blood clot are carried to the lungs occluding the vessel and obstructing blood flow to lungsSymptoms of a PESudden, sharp chesy pain, tachypnea, dyspnea, cough, pulmonary crackles, hemoptysis, decreased O2 sats Transfer to ICUTherapeutic management of pulmonary embolismBedrest with HOB elevated Anticoagulant therapy:IVHeparin Monitor O2 AnalgesicsNursing care for PERapid response Monitor resp rate Auscultate lung sounds Pulse oximetry, O2 as needed Report cough, air hunger, dyspnea, tachcardia, pallor, and cyanosis Heparin protocolDefine postpartum infectionFever >100.4℉ occuring on at least 2 successive days of the first 10 days after the first 24 hrs following childbirthPathology of postpartum infectionStreptococcal, staph aureus, gonococcal organismsWhat are the risk factors for postpartum infection?Prolonged ROM, meconium stained fluid, multiple vaginal exams, op vag birth, c/s, internal monitoring, retained placenta, lacerations, obesity, urinary cathHow may postpartum infections be prevented?Good hand washing Aseptic technique Proper pericare Change pads q3-4 hrsWhat is endometritis?Infection of the uterus, usually starts from placental site Etiology involves normal organisms found in vag or cervix, strep BSymptoms of endometritisFever, chills, malaise, anorexia, abdominal pain, cramping, uterine tenderness, purulent, foul smelling lochia, increased WBCs Occurs within first 24-48 hrs of delivery Higher incidence with c/s Cultures of uterine cavity for dxTherapeutic management of endometritisBroad spectrum IV antibiotics until cultures reported Antipyretics PRN as ordered Labs: CBC, blood cultures, urine culture (UTI) Analgesics, assess lochia, VS Fowler's position for comfort Monitor for worsening symptoms: N, V, abd distention, absent bowel sounds, severe abd painComplications of endometritisSalpinitis-inflammation of fallopian tubes Oophoritis-inflammation and infection of the ovaries Peritonitis-inflammation of the membrane lining the walls of the abd and pelvic cavity Paraltytic illeus-a distended, board like abd with absent bowel soundsWound infectionCommon sites: c/s incision Episiotomy, lacerations Risk factors: diabetes, obesity, malnutrition, long labor, preexisting infection, poor suturing techniqueSymptoms of wound infectionEdema, warmth, redness, tenderness, purulent drainage, fever, pain at siteTherapeutic management of infectionIncision and drainage of affected area, cultures, antibiotics, analgesics and warm compressesWhat is Cystitis related to?Foley cath, urinary stasis, urinary retention, vag exams, epidural anesth, macrosomic baby, operative deliverySymptoms of cystitisBurning, suprapubic pain, dysuria, urgency, frequent urination, small voidings, fever 1st or 2nd day postpartumManagement of cystitisAdmin antibiotics Monitor labs:urinalysis, urine, C&S, CBC, Encourage acidic fluids, 3,000 mL/ day ie cranberry juice Good Peri care Encourage urinationMastitisInfected milk ducts after flow establishedEtiology of mastitisSpreading of staphylococcus aureusPrevention of mastitisFrequent feedings, empty breasts, prevent cracked nipplesSigns and symptoms of mastitisLocalized area of redness and inflammation of one breast, increased HR, purulent drainage, fatigue & aching muscles, fever >101.1, chills, malaise and headacheTherapeutic management of mastitisCulture expressed milk Antiobiotics Continue to breastfeed q2-4 hrs Continuous emptying of breastmilk Application of heat to affected areas Application of cold after feeding Supportive bra Analgesics, rest, lots of fluidsEducating mom to prevent mastitisCorrect latch by infant and removal from breast, air dry nipples after feedingWhat are the characteristics of a normal full term newborn?Normal respiratory rate- 30-60,rhythmic and equal, irregular resp normal in newborn, short periods of apnea are normal <20 sec HR. At least 100 immediately after birth, normal 120-160 Normal glucose 50-90 after day 1Describe nursing care for the normal full term newbornStimulate and dry the baby, be sure to remove wet linens, ABC skin to skin with mom APGAR Bonding Medications Vit K Erythromycin Measurements: weight, length, head, chestHow do we maintain a netral thermal environment for baby?Dry thoroughly Remove wet linens Hat Skin on skin Pre warm warmer, blankets, clothing Delay bath until temp stable Avoid draftsHyperthermiaIncreased metabolic rate Increased need for O2 and glucose Peripheral vasodilation Increased insensible fluid loss Due to: Over heating, maternal fever, sepsis, CNS and cardiac disorders, dehydrationWhat needs to be done in a newborn screening and immunizationsMandated: Metabolic/ genetic conditions Heel stick (done after 24 hrs old) PKU, galactosemia, hemocystinuria, hypothyroid, sickle cell, thylassemia, maple syrup urine disease Cystic fibrosis may be done (not mandated, need consent) Hep B (need consent) Erythromycin opthalmic Hearing screeningWhat initiates the first breath?Most critical and immediate physiological change Chemoreceptors sense a decrease of oxygen and pH as the increase of CO2 which stimulate the resp center Sudden decrease in temp Chest compression followed by recoil forces fluid out and draws air in Stimulation:touch, sound, lights lung inflation occurs and causes the pulmonary artery dilation and allows blood into the lungs Surfactant decreases the surface tension in the alveoliWhat would be abnormal for tespirations?Out of normal range of 30-60, should be rhythmic with equal chest expansion Assess for flaring, grunting, retractionsWhat do we assess for circulation?HR at least 100 immediately after birth, normal 120-160 Assess color, pulses, (brachial, femoral) Assess heart rate for rhythm and heart soundsWhat equipment do we need to make sure we have and is working before delivery?Radiant warmer, oxygen flow, Ambu bag, Suction equipment, intubation equipment, medsWhat factors predispose an infant to cold stress?Thin skin with blood vessels close to the surface Lack of ability to shiver Limited use of voluntary muscles Large body surface area compared to weight Lack of subcutaneous fat (provides insulation) No ability to alter clothing Inability to communicate Higher metabolic rateMethods of loss of body heatConduction- direct contact Evaporation-wet skin Convection- air current Radiation--indirect contactCold stressExcessive hrat loss that leads to hypothermia and results in the utilization of compensatory mechanisms to maintain body temp.What body systems increase when baby is cold stressed?Resp rate HR O2 use Metabolic rate Muscle activity Peripheral vascular constrictionRisk faactors for cold stressPremie Small for gest age Hypoglycemia Prolonged resuscitation efforts Sepsis Neurological, endocrine, or cardiorespiratory problems Congenital anomolies: ie. Spina bifidaSymptoms of cold stressTemp <97.7 (normal axillary 97.7-99) Cool skin poor perfusion Lethargy Pallor Tachypnea Grunting Hypoglycemia Hypotonia (decreased tone) Jittery Weak suckConsequences of cold stressMetabolism of brown fat/adipose tissue Highly dense and vascular adipose tissue Non shivering thermogenesis Increase metabolic rate for heat generation Depletion of glucose Decrease in surfactant resulting in respiratory distress Decrease blood oxygenation causes vasoconstriction of the pulmonary vessels and returns to fetal circulationNursing interventions for hyperthermiaTreat underlying cause Ie: sepsis, dehydration, hypoxia, acidosis Assess environmental temperature Modify heat sources Incubator or radiant warmer settings Remove excessive bundling/swaddling Assess, intervention, reassessGestational age assessmentTerm 37-42 weeks Preterm <37weeks Very preterm 32 weeks Premature 32-34 weeks Post term >42 weeksGestational age assessmentNeuromuscular Posture (flexion vs extension) Arm recoil Scarf sign/ hand across body- premie no resistance Square window- bend hand at wrist-more flexion, more maturePhysicaal gestational age assessmentSkin (dry, peeling-mature) Lanugo Plantar creases - few premie Vernix- increased- premie Breast buds Eye pinna flat GenitalsPKUAutosomal recessive disorder Toxic accumulation of phenylalanine (amino acid) needed for normal growth and development Results in: eczema, convulsions, hyperactivity, lower IQCircumcisionInformed consent Able to void prior Pain management before, during and after the procedure Assess for bleedingNursing interventions post circumcisionAssess for bleeding Assess for voiding after procedures Assess for signs of infection Educate parents Gomco/Mogen-Vaseline gauze Plastibell-no vaseline, leave in place, do not pull on ring or stringContraindications to breastfeedingIllegal drug use, active TB, HIV, cancer meds, and other medsNursing role pre opEstablish baseline Physical assessment Emotional assessment Anxiety, fear, hopes Prior anesthesia Past med Hx Allergies to meds/latex Genetic defects Pre op testing completedCommon complications with preterm birth, 34-37 wksRespiratory distress syndrome Retinopathy of prematurity Bronchopulomary dysplasia Patent ductus arteriosis (PDA) Periventricular intraventricular hemorrhage Necrotizing enterocolitis (NEC)Symptoms of respiratory distressDifficulty breathing, tachypnea, retractions, grunting, nasal flaring, poor color, decreased breath sounds, Xray changesBronchopulmonary dysplasiaChronic lung condition Beyond 28 days more at risk for fibrosis, atelectasis, increased pulmonary resistance, over distention leading to reduced lung compliance and pulmonary functionTORCHToxoplasmosis Other (hep B) Rubella CMV HerpesNursing care for neonatal abstinance syndromeDecrease environmental stimuli Pacifier HOB elevated after feeds High calorie formula Encourage bonding Neonatal abstinance score Meds: phenobarbital, morphine, paregoric Social services consult