OB Cornell Notes Ch 24 & 17

C-section

Birth w abdominal incision into uterus; slightly more hazardous than vag 

• Healthy People goal is to reduce rate of c-births among low-risk patients having first child 

• Prophylactic measure to alleviate problems of birth like cephalopelvic disproportion, breech or multiple fetus births, or failure to progress labor

Amniotomy

artificial rupturing membranes with a knife or som during labor if they don’t rupture spontaneously 

• Momentary risk for cord prolapse 

• Only perform if fetal head is well applied to cervix. Always measure FHR immediately after rupture 

Episiotomy

Surgical incision of perineum to release pressure on the fetal head with birth and possibly shorten the last portion of the second stage of labor 

• Not done midline so it doesn’t split through anus. Mediolaterally 

Pre-operative teaching

• For c-section, acquaint pt with special equipment used (inform them whats abt to happen).

• Teach pt exercises to maintain respiratory and circulatory function and prevent postoperative complications (e.g. early ambulation, turning, incentive spirometer). Prevents post-op complications.

Internal Electric Monitoring

Most precise method to monitor FHR & contractions 

• Pass a pressure-sensing catheter through the vagina and into uterus after membranes ruptured, SCREW TO BABY HEAD

Scalp stimulation

If FHR variability is depressed during labor, this helps assess welfare of the fetus

• Stim baby scalp w finger (through dilated cervix)

• baby should have momentary inc FHR

  • if in distress, FHR acceleration will NOT occur

Uterus complication

Because uterus is handled during c-section birth, may not contract well afterward 

• Can lead to postpartum hemorrhage 

Bladder complication

For provider to reach uterus, bladder must be displaced anteriorly

• bladder mmay not sense filling as well post-procedure

Intestine complication

Paralytic ileus or halting of function with obstruction may occur

Lower extremity circulation complication

Thrombophlebitis from impaired blood flow is possible (e.g. DVT)

Post-op exercises

Deep breathing

• Stasis of mucus can cause infection

• prevent by doing 5-10 deep breaths/hr, hold for 1-2s.

Turning

• Preventing respiratory and circulatory statis

Incentive spirometry

• Used 3-4 times/day to encourage deep breathing

• purpose to fully aerate lung spaces, so most models triggered by inhalation

Ambulation

• Most effective way to stim lower extremity circulation after c-section

Discharge planning

• Do not lift any object heavier than 10lbs

• Do not walk up stairs more than once a day for first 2wks

• Resume sex as soon as comfortable 

Warning signs

• Report redness/drainage at c-section incision line

• lochia heavier than normal menstrual period

• abd pain other than at suture line

Psychological changes postpartum and Nursing Care: (6 weeks-yr postpartum) 

Psychological

• Attachment to newborn

  • skin-to-skin for early attachment

  • En face position: direct eye contact w newborn, good sign of engrossment - how well a parent is attaching to kid

• Feeling overlooked or forgotten

• Disillusionment: disappointment after birth (tell mother this is normal❗)

• postpartal blues: 50% patients experience ‘baby blues’, breastfeeding can help

Physiologic changes postpartum & Nursing care

Uterus

• Involution involves sealing of placenta area (prevent bleeding) and reducing size to pregestational size

• Takes 6 weeks

Fundus

• after birth, fundus palpable halfway btwn umbilicus and pubic bone for a few min

• one hr later, rises to level of umbilicus (remains here for 24hrs)

• decreases by 1cm/day

Lochia

• residual blood, fragments of decidua, WBC, mucus, bacteria

• Expected findings:

  • 1-3d: red, moderate/heavy

  • 3-7d: brownish

  • 7-14d: serous

  • 2-3wks: yellowish

  • 3-4wks: grayish

Cervix

• Internal os closes as before

• external os used to be round, now it has slits on the side/stellate shaped

Vagina

• soft, some rugae, diameter greater than normal

Perineum

• Pressure during birth → perineum is endematous and tender immediately after

  • suggest comfort (gentle pillow, doughnut pad, warm packs, analgesics)

Nursing care for Urinary System changes

• Extensive diaphoresis (sweating) and diuresis (excessive urine prod) almost immediately 

• Assess abdomen freq for overdistention

• Second gauge of whether bladder is full: Uterine displacement and lack of contraction

Nursing care for Circulatory System changes

• Diuresis 2-5d postpartum & blood loss at birth

  • happens so fast that BV returns to pre-preg in 1-2wks

• bilateral ankle edema (shouldn’t go above knees)

Nursing care for Gastrointestinal System changes

• bowel sounds active, BM slow bc of relaxin, difficult because of episiotomy/hemorrhoids

• eat fiber, fruits, stool softener

Nursing care for Integumentary System changes

• stretch marks

• overstretching/separation of abs

• modified ab exercises or surgery may be needed

Lactation

Lactogenesis II is often when the “milk has come in” , also known as engorgement and occurs from birth to 5-10 days postpartum; this is often termed “transitional milk.” 

Postpartum Complication Warning Signs: 

Respiratory: Pain in chest, difficulty breathing 

Neurologic: Seizures, persistent headache, visual changes 

Mental health: thoughts of hurting self or others 

Infection: temp >100.4, edema/redness of lower extremities, incision not healing 

Hemorrhage: Excessive bleeding, soaking through one pad/hr or larger than quarter size clots 

CALL 911 + HEALTHCARE PROVIDER