Postpartum and Newborn (MC test 2)

What is the postpartum period

* 6 week time frame between birth of the baby and return of the organs to pre-pregnancy state

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Immediate = first 24 h

Early = first week

Late= 2-6 week

Involution

* process of the uterus returning to a pre pregnant state
* begins after expulsion of placenta
* uterus reduces in size and weight rapidly
* caused by sudden decrease in estrogen and progesterone

What factors SLOW involution

* prolonged labor
* incomplete expulsion of placenta
* anesthesia
* previous labors
* full bladder

What can INCREASE involution

* uncomplicated birth
* early ambulation
* breastfeeing

What method is used to asses uterine involution

Fundal height measurement

* descent of uterus usually 1 cm per day

Before preforming fundal massage, what do you instruct the women to do?

Empty her bladder

How to preform fundal massage

* cup one hand above the symphisis pubis to support the lower uterine segment


* With the other hand palpate the top of fundus, if not firm, lightly massage
* indicated if the uterus is boggy, causing increased bleeding

Sub-involution

* failure of the uterus to go back to pre pregnancy state
* usually caused by retained placental fragments

Afterpains

* uterine contractions occurring first 2-3 days post birth
* caused by hormone oxytocin to contract uterus and stop bleeding
* breastfeeding can cause worsening afterpains due to the increase of oxytocin during this time
* NSAIDS are most effective

Lochia

* postpartum vaginal discharge
* contains blood from placental site, uterine tissue, mucus
* fleshy odor

Different types of lochia

Lochia rubia = bright red (1-3 days postpartum)

Lochia serosa= pink to brown (4-10 days)

Lochia Alba = yellowish (10 days to 6 weeks)

Assessment of lochia/bleeding

* fundus firmness (not firm = excessive bleeding possible)
* weighing pads (1mL of blood = 1 gram)
* Lochia increases briefly during ambulation (normal)
* excessive bleeding can indicate retained placenta, sub involution or infection

REEDA scale

Assessment of episiotomy site

* Redness
* edema
* eccymosis (bruising)
* discharge
* approximation

Nursing care for pain of perineum

* cold sitz baths
* warm and cold application
* pads with witch hazel
* medications

During the first few days what hormone regarding muscles decreases?

Relaxin

* ligaments and cartridge of the pelvis begin to return to pre pregnancy state

What should the nurse do to asses for a beginning DVT?

* passive dorsiflexion of women's feet that causes pain is a POSITIVE HOMANS sign.
* May be an early sign of venus thrombosis.
* Also watch for redness, swelling and warmth of calf

How much blood loss is normal during birth?

Vaginal = 200-500 mL

C-section 1,000 mL

* more than that is considered a hemorrhage

How is fluid built up during pregnancy eliminated?

* increased urinary output (may be as much as 3000ml/day)
* heavy sweating (diaphoresis)

Labs that change after birth

* temporary rise in Hct and Hgb (returns to normal in 2-4 wks)
* lekocytosis (incresed WBC) (returns to normal in 10 days
* GFR increased (returns to normal in 8 weeks or less)
* Mild protienuria as a result of uterine cell breakdown
* fibrinogen remains high (returns to normal within 2 weeks)

Changes to VS after birth

* temp may be 100.4 or above during first 24 hours, but if it remains high could indiate infection
* Bradycardia for first 6-8 days postpartum
* B/P should be the SAME

Factors that cause urinary retention post partum

* tissue around the bladder is traumatized
* anesthetic drugs
* Bladder had reduced ability to contract
* Decreased sensation of needing to void

WATCH FOR URINARY RETENTION

Complications of urinary retention postpartum

* bladder distends, pushing the uterus to the side which causes uterus to not be able to contract
* inability of the uterus to contract can lead to excessive bleeding
* MAKE SURE TO MONITOR URINARY OUTPUT to prevent
* urinate q2-3 hours to prevent

Hormone changes post birth

* estrogen and progesterone drop right after birth
* if NOT breastfeeding, estrogen returns in 3 weeks which leads to return of the period in about 3 months
* ovulation returns in 1 month
* Prolactin increases in women who are breastfeeding to stimulate milk
* oxytocin triggers the release of milk (also contractions which is why some feel afterpains while breastfeeding)

How is weight lost after pregnancy

* loses 10-13 lbs right away from baby and placenta
* lochia
* increased urination and perspiration
* involution
* fat stored for feeding is gradually used up as the women breastfeeds
* normal weight is back by 6mo

What are some major causes of hemorrhage postpartum

Early Postpartum Hemorrhage:

* uterine lacerations
* uterine atony (lack of proper contraction of uterus)

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Late Postpartum Hemorrhage:

* retained placental fragments (causes inability for uterus to contract all the way)
* decreased involution

Methods to relive discomfort from breast engorgement

* supportive bra worn for 72 hours
* ice packs
* analgesics (ibuprofen, Tylenol)

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Engorgement usually occurs 3-5 days postpartum

phases of postpartum adaption

Phase 1: Taking in: mother is willing to let others do things for her, hold the baby, ect. Focus is on recovery

Phase 2: Taking hold: Mother becomes interested in caring for infants, increased concern. BEST TIME FOR TEACHING

Phase 3: Letting go: giving up previous lifestyle, accepting the real child (not the ideal)

Postpartum check acronym

B: breasts and nipples (engorgement, lactation, redness)

U: Uterus (fundal height, location, firmness)

B: Bladder (intake/output frequency, pain)

B: Bowel (BM?)

L: Lochia (amount, color, odor, clots?)

E: Episiotomy (REEDA scale)

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H: Homans Sign (passive dorsiflextion of foot causing pain)

E: Emotional status

Is postpartum chill (shaking) normal/common after birth

* yes, as long as it is not accompanied by a fever

Cold vs heat on perinium

Cold: for first 24 hours

Heat: after 24h

Nursing management for application of pain creams to perinial area

* apply after a sitz bath
* wait 1-2 minutes before putting on pad

Sexual intercourse after birth

* safe after discharge turns white
* episiotimy is healed (about 3 weeks after birth)
* use contraceptives!! Breastfeeding is not effective
* oral contraceptives begin 2-3 weeks after birth for non-lactating, and as soon as lactation is well established in lactating women

Identifying amount of fluid on perineal pad

Scant= 2 inch stain (10 mL)

Small = 4 inch stain (10-25 mL)

Moderate = 6 inch stain (25-50 mL)

Large = >6 inch stain (50-80 mL)

Postpartum hemorrhage

Blood loss more than 500 mL for a vaginal birth and 1000 mL for c section

* greatest risk in the first 24h
* can be caused by: uterine atony, laceration in early, later hemorrhage may be caused by retained placental fragments or sub-involution

When is peri pad changed

* after BM
* after voiding
* if soiled

Physical s/s of hemmorage

* cold, clammy skin
* increased HR and RR
* Pale skin
* dizziness

Uterine atony

inability of the **myometrium** to contract

* vessels cannot heal
* occurs in first hours after birth

Hematoma

* caused by trauma
* bulging mass
* may form in upper portion of vagina, leading to massive hemorrhage
* S/S = perineal pain **(not usually bleeding),** edema, uterus may be firm, decreased B/P, inability to void, urge to defecate

Normal height of fundus post birth

* after birth, fundus is 2 cm below umbilicus
* decreases 1 fingerbreadth below the umbilicus
* after 2 weeks, fundus cannot be seen or felt
* A fundus that is higher than normal after birth may be because of sub involution

Anahpylactic syndrome of pregnancy (amniotic fluid embolism)

* entrance of amniotic fluid into maternal circulation
* triggers release of cells that cause pulmonary artery hypoxia
* hypoxia of pulmonary artery causes heart muscle damage and can lead to L sided heart failure

Mastitis

Infection of the breasts

* usually cased by entrance of bacteria into from cracks in nipples
* can be caused by blocked duct/**stasis of milk**, nipple trauma, poor breastfeeding, inadequate hand-washing in between peri care and breast care
* S/S = painful reddened area, enlarged glands, fever, chills, malaise

Treated by antibiotics, ice, warm packs, supportive bra

Diastasis Recti

Separated abdominal muscles

* strengthening exsersize to fix

Colostrum

* yellowish fluid secreted by breasts
* nutrient rich
* stimulated peristalsis in baby
* normal

Are bowels sluggish after birth?

Yes! Constipation common

Risk factors for postpartum hemorrhage

* oxytocin labor induction/augmentation
* multiple fetuses (twins)
* preeclampsia
* operative delivery
* chorioamnionitis (infected amniotic fluid)
* hx of past uterine surgery or past hemorrhage
* prolonged or difficult labor
* placenta previa
* aburuptio placente
* large baby
* episiotomy
* traumatic delivery, use of forceps or vacuum
* thrombocytopenia (low platelets)
* fetal demise

Thrombocytopenia S/S

* nosebleeds
* ecchymosis
* petechiae on lower extremities
* bleeding from gums

Postpartum (puerperal) infection

Endometritis most common

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higher risk for:


1. c section births
2. Foley caths
3. episiotiomy
4. frequent vaginal exams
5. retained placenta
6. chorioamnionitis (infected amniotic fluid)
7. traumatic birth

Normal vital signs for the newborn

RR: 30-60/min

* periods of apnea not greater than 15 seconds = normal

HR: 110-160

* auscultate all heart sounds (APTM) to look for murmurs

B/P: 60-80/40-50

Weight: 5.5-8.8

Length: 18-22 inches

Newborn temperature

Only take auxiliary temp

* approx. same temp of mother at birth, may drop 1- 2 degrees but should return to normal in 8 hrs

HIGH RISK for hyPOthermia

* cold stress causes oxygen demands increase and acidosis can occur

Non-shivering thermogenesis

Because newborns cannot shiver to increase body heat, they use non-shivering themogenisis

* uses the metabolism of brown adipose tissue (brown fat)
* Brown fat metabolizes and creates warmth

**If Infant is exposed to lots of cold stress, brown fat stores are depleted causing impaired thermoregulation**

* drugs such as meperidine (demorol) given during labor can mess with brown fat

Where is brown fat found and when does it go away?

found on

* neck
* axille
* around kidneys
* adrenals
* sternum
* along abdominal aorta

Dissapears after three months

Cold stress potential consequences

* Hypoglycemia (CBG less than 40)
* Acidosis
* reopening of fetal circulation

Skin asessment of the infant

Acrocyanosis (bluish hands and feet) normal for first 6-12 hrs post birth

Pallor/dusky, cyanosis

* decreased O2, CNS depression, anemia

Harlequin sign

* half of body is pale, other half is red

Jaundice

**Physiologic Jaundice**

* benign
* r/t breakdown of RBC and liver immaturity
* increase in bilirubin
* usually shows up after 3rd day of life

**Pathological Jaundice**

* within the first 24 hours
* bilirubin more than 12
* r/t RH or ABO incompatibility
* shows up BEFORE 3rd day of life

Hydrocephalus

* excessive cerebral fluid within brain cavity surrounding brain

Fontanel abnormabolities

* bulging when baby is not crying = increased ICP
* depressed fontanel = dehydration
* third fontanel can = down syndrome

Phenalkeytoneuria (PKU)

Newborn cannot metabolize phenylalanine which is in protein, including breast milk

* levels accumulate in blood
* causes mental problems
* __**Gutherine**__ test to determine
* goal to maintain levels between 2-10

Ear/eye height

Top of ear should be level with other canthus of eye

* low set ears can indicate chromosomal abnormalities

Newborn tremors

* newborn tremors are common
* asses to ensure they are not seizures

What indicates hip dysplasia

Asymmetric creases on thighs + limited hip abduction

Newborn reflexes

* **Rooting** = searching for nipple
* **Gag:** on stimulation of uvula
* **Blinking:** stimulate with flashlight
* **Moro’s:** allowing head and trunk of newborn to fall
* T**onic neck:** head turns to one side quickly, arm and leg extend on that side (fencing posture )
* **Crawl:** placed on abd will make crawling motions
* **Dance/step:** stimulates walking (while holding up) dissapears and three weeks

Newborn car safety

* rear facing seat until 2
* safety seat reclines 45 degrees to maintain airway

How should newborns be placed after feeding

* on thier right side to prevent aspiration

Should you wait to bathe an infant after feeding?

Yes, risk of regurgitation due to increased handling

Preventing SIDS

* firm crib mattress
* placed on back during sleep!

Nutrition during breastfeeding

* 500 more calories than non pregnant diet
* Protein 65mg/day
* 8-10 glasses of non caffeinated liquid per day
* some foods the mother eats may cause infant gas

Stages of milk production

Colostrum = first 3-4 days postpartum

* easier to digest
* antibodies

Transitional Milk

* between mature and colostrum
* 5 days to two weeks

Mature milk

* looks like skim milk can be bluish

How long on each breast for feeding

15-20 min

what position should the newborn be in during feeding

chest to chest (babies chest facing mothers chest)

* turning the infants head may interfere with swallowing

Hand position during breastfeeding

Hand in a C position

* supporting breast from below
* thumb above the nipple below the areola

Storing breast milk

* store in glass or hard plastic
* do not keep at room temp for over 4 hours
* DO NOT use plastic with numbers 3,6 or 7 on the bottom
* can stay in fridge for 5 days
* fridge freezer for 2 weeks
* deep freezer for 12 months

Preterm/premature infant

Born before 38 weeks, regardless of weight

* late preterm is between 34-36 weeks

Term infant

Born between 38-42 weeks, regardless of weight

Low birth weight

Newborn who weighs less than 5.5 lbs or 2500g

Small for gestational age

Below the 10th percentile for weight

* prone to hypoglycemia r/t glucagon stores being depleted
* calorie needs are high

Large for gestational age

Above the 90th percentile for weight

* more than 8.8 lbs

Postterm

Born after 42 weeks

What can cause fetal growth restriction (leading to SGA)

* small parents
* reduced blood flow to uterus (DM,hypertension, kidney disease)
* smoking + substance abuse
* malnutrition of mother
* placental abnormalities
* multi fetal pregnancy

Size of newborn if mother has DM

In women with DM who do not have vascular changes

* high glucose levels cross into placenta, leading to large for gestational age newborn

Complication of post-term newborns

* hypoxia due to placenta not giving adequate oxygenation anymore due to it being old

When is the newborns resp system fully developed?

After 35 weeks

Nutrition intake is considered sufficient when the preterm newborn gains ___ per day

20-30 grams per day

kangaroo care

Skin to skin contact

Retinopothy of prematurity is caused by

Oxygen toxicity

Most premature infants catch up by__

24 months (2 years) of age

Physical characteristics of preterm newborn

* wrinkled skin
* lanugo covered skin
* weak cry
* poor muscle tone

Physical characteristics of post-term newborn

* thin with loose skin
* cracked and dry skin, leathery appearance
* long fingernails
* little lanugo

Blanch test for jaundice

Apply pressure on skin over a bony area (nose, forehead, sternum)

* yellow tinge in the blanched area indicated jaundice

S/S of hypoglycemia in newborn

* lethargy
* jitteriness
* poor feeding
* tachapnea
* apnea
* sweating
* shrill cry
* low temperature

Spina Bifida

Imperfect closure of spinal vertibre

* small opening on spine, may have protrusions
* Needs surgical correction
* protect membrane w/ sterile moist dressing to prevent drying

Infants of DM mothers have

High glucose in the fetus during pregnancy

* high maternal glucose is cut off when cord is clamped
* prone to hypoglycemia

Respiratory distress syndrome

Caused by surfactent (keeps alveoli from collapsing and helps gas exchange) deficiency leading to poor gas exchange

* respiratory acidosis can occur

S/S of dehydration in the infant

* urine output of less than 1mL/kg/hr
* weight loss
* dry MM
* no skin turgor
* sunken fontanells

Nursing care for the infant receiving photo-therapy

* keep eyes and genitalia covered
* keep baby naked
* do not apply lotions or creams before
* remove from photo-therapy q4h and remove mask to check for injury
* Reposition q2h
* check aux temp q4h

is bronze discoloration and maculopapular skin rash during photo-therapy normal?

Yes, this is normal

* Do however watch for sunken fontanells indicating dehydration