OB/PEDS - Exam 3

What are other names for postpartum?

• Postpartum: 6 weeks after delivery

• Puerperium

• Postpartal period

• 4th trimester

Postpartum Family Wellness

• Family centered care

• Information

• Time for interaction with baby

• Supportive environment

  • Wait for assessment times depending on situation

Postpartum - Principles of Nursing Care

• Revitalization of energy (mental and physical)

• Normal Involution (uterus shrinking)

• Preventing infection (reproductive and urinary systems)

• Promoting healing of tissue

• Normal lactation or suppression (breastfeeding and education of suppressing milk)

Postpartum - Physiological Changes

*Know their baseline

• Vital signs:

  • Temperature

    • Greater than or = to 100.4 = fever = infection

    • Increased in first 24 hours

  • Blood pressure

    • Decreased and HR increased with blood loss

    • HTN won’t resolve fast

  • Pulse

    • Bradycardia

    • Tachycardia

Assessment of the Postpartum Client

• Focus on reproductive and urinary within head-to-toe

• BUBBLEEE

  • Breast

  • Uterus

  • Bowel

  • Bladder

  • Lochia

  • Episiotomy

  • Extremities

  • Emotions

Postpartum Assessment - Breast

• BF or formula?

  • BF - in-depth assessment

  • Formula - don’t palpate breast (ask questions rather), tight fitting bra

• Inspect

  • Note size, color, shape

  • Nipples (type)

    • 3 types: everted (normal), flat (difficult for latch), inverted (difficult for latch) - see picture

  • Engorgement

  • Complications

    • Bruising, redness, cracks, bleeding

      • Issues with latch (need whole nipple for latch)

  • Palpate → soft (colostrum) or firm (producing milk)

When can you begin to breastfeed?

Right away (within the first hour), otherwise baby goes into a recovery period (18-24 hours)

Postpartum Assessment - Uterus

• Fundus (top of uterus)

• Involution - cramping of uterus due to shrinking and clotting vessels leftover from placenta

  • Myometrial contractions

  • Autolysis

• Firm vs. boggy

  • Firm uterus is tight, contracted, and well-toned, whereas a boggy uterus is soft, spongy, mushy, or relaxed

• Fingerbreadths

Postpartum Assessment - Fundus

• Uterus is midline of the abdomen at the umbilicus after delivery

  • Up to the right = full bladder

    • Concern if fundus is above the umbilicus and not firm

• Fundus will shrink 1 fingerbreadth/day post delivery

• Note location

• Note firm (contracting) or boggy (mushy sponge; not contracting - circular motions with fingers and fundus starts contractions)

• ALWAYS support with bottom hand to avoid inverting the uterus

• C/S → lower the hand above the incision line (if transverse; if vertical go to the sides)

Postpartum Assessment - Abdomen

• Bowel Sounds first!

• C-section

  • Low transverse vs. vertical

  • Dressing stays on for 24 hours then we assess:

    • REEDA

      • Redness

      • Edema

      • Ecchymosis

      • Drainage

      • Approximation

Postpartum Assessment - Bladder

• Diuresis - lots of output (due to fluids, epidural)

• Void within 6-8 hours after delivery or after catheter removal (usually 3 voids)

• Frequent small voids may indicate retention and overflow

  • Due to fear, risk for infection

  • Exhaust all methods to allow them to pee

Postpartum Assessment - Bowels

• Bowel elimination usually occurs 2-3 days after delivery

• Use of stool softeners

• Fluids

• C/S → want bowl sounds and passing gas (movement helps)

Postpartum Assessment - Lochia

Discharge after delivery

*Red for 3-4 days

Postpartum Assessment - Lochia Measurement

• Scant, light, moderate, and heavy

• When did she change pad last? (every 2-3 hours is expected)

• Note TACO

  • Type

  • Amount (look at pad and bed)

  • Clots (large is abnormal)

  • Odor (foul = infection)

Postpartum - Vaginal Changes

• Poor muscle tone

• Edema → cold packs (decreases edema and numbs) for the first 24 hours, warm packs after 24 hours

• Bruising

• Lacerations

• Episiotomy - a surgical cut made through the perineum (the tissue and muscle between the vaginal opening and the anus) during the second stage of vaginal childbirth to widen the birth opening

Postpartum Assessment - Episiotomy

*Turn to side to assess, can visualize hemorrhoids

• REEDA

  • Redness

  • Ecchymosis

  • Edema

  • Drainage

  • Approximation

Postpartum Assessment - Extremities

• Ask: do you have pain in your arms and legs?

• Edema

  • +1-+2 (resolves on own)

  • Common in lower extremities (can be due to potocyin → retains fluid)

• Assess for clots

  • Pain/tenderness, redness, swelling, warmth

• Homan’s sign - a clinical test where a patient feels pain or discomfort in the calf or behind the knee when the foot is forcibly and abruptly pulled upward (dorsiflexed) while the knee is flexed

Postpartum Assessment - Emotions

*Assess the whole time

• Emotional status

• Bonding and attachment

Postpartum Affective Disorders - Postpartum Blues vs Postpartum Depression vs Psychosis

Transient period of depression that occurs in most women during first week or two after birth

• Edinburg Postnatal Depression Scale - 10-item self-report questionnaire used to screen for perinatal and postpartum depression

Postpartum - Nursing Interventions to Promote Health

• Complete postpartum assessment

• Promote urinary and bowel function

• Promote perineal healing and teach self care measures

• Provide breast care (no soap/lotions) and teach self care measures

• Teach abdominal and pelvic strengthening exercises (kegele exercises 25-30 reps several times a day)

Postpartum Hemorrhage

*Most common

• Early - occur in first 24 hours

• Late - occur after first 24 hours

• Massive vs. slow and steady (still a hemorrhage!)

Postpartum Hemorrhage Pathophysiology

• Tone

  • Uterine atony (cause of a full bladder?)

  • No contractions = bleeding

• Trauma

  • Lacerations and hematomas

• Tissue

  • Retained placenta fragments, clots, membranes left. inside uterus

• Thrombin

  • Inherited and acquired blood disorders (EX> Von Willebrand disease, disseminated intravasulcar coagulation, thrombotic thrombocytopenic purpura)

• Traction

  • Pulling on umbilical cord to extract placenta before it separates

Postpartum Hemorrhage - Clinical Risk Factors

• Polyhydramnios → increased amniotic fluid

• Multifetal gestation → twins, etc…

• Macrosomia

• Rapid labor

• Prolonged labor

• Incomplete placenta at birth

• Atonic uterus

• Previous uterine surgery

• Malposition of the fetus

• Forceful pulling when placenta isn’t separated

• Hereditary inheritance

• History of PPH

Postpartum Hemorrhage - Nursing Interventions

• Uterine massage (firms uterus)

• Frequent voiding

• Assess H&H (iron tablet)

• Meds

  • Oxytocin (Pitocin) → 1st line

  • Cytotec

  • Methergine

  • Hemabate

• Assess urinary output

• Encourage rest

• Encourage foods high in iron

• Safety

  • Rise slowly to minimize orthostatic hypotension

  • Seated while holding the newborn

*Not in order

Puerperal Infection

An infection of the reproductive tract within the first 10 days after birth or abortion (+ elective)

Puerperal Infection - Predisposing Factors

• Traumatic delivery

• Prolonged/difficult labor

• Dehydration

• Excessive vaginal exams

• PROM (premature rupture of membranes)

• Anemia

• Retained Placental Fragments

• Hemorrhage

Puerperal Infection - Prevention of Infection

• Good perineal care

• Hygiene practices

• Thorough hand washing

• Adequate fluid intake

• Diet high in protein and Vitamin C

Mastitis

Inflammation of the breast tissue, generally caused by staphylococus organisms (red, warm, unilateral)

Prevention of Mastitis

• Proper feeding techniques

• Supportive bra at all times to avoid milk stasis

• Good hand washing

• Prompt attention to blocked milk ducts

Treatment for Mastitis

• Regular, complete emptying of the breasts

• Good infant positioning and latch-on

• Antibiotics (full course; can BF on antibiotics)

• Report flu-like symptoms

Deep Vein Thrombosis

• Formation of blood clot in lower extremities

• 3 major causes:

  • Hypercoagulability of blood

  • Venous stasis

  • Injury to epithelium of the blood vessel

*SCD (compression devices) 1st 24 hours c/s moms

Deep Vein Thrombosis - Treatment

• Avoiding circulatory stasis

• Anticoagulants

• Safety

Common Postpartum Discomforts

• PP chill

• After pains (tx with ibuprofen, increased cramping when BF)

• Breast/nipple soreness

• Urinary stasis

• Constipation

• Perineal discomfort

• Hemorrhoid

Postpartum - Nutrition

• Increased calories for BF

• Fluids

• Prenatal vitamin (continue to take while healing)

Activity After Delivery

• Sex

  • Resume after episiotomy healed and lochia stopped

  • Lubrication may be required

  • Contraception

  • Potential limiting factors

  • *Resume after 6 weeks postpartum

• General activity

  • Sleep and rest

  • Exercise

• Increase in bleeding or pain indicated re-evaluation of activity

Postpartum - Teaching

• Self-care

• Infant care

• Infant nutrition

• Breast feeding

Postpartum - Self-Care Teaching

• Breast

• General activity

• Diet

• Exercise

• Pelvic rest

• Peri-care

• Cesarean birth

• Medications

• Birth control

• Doctors appointment

Postpartum - Birth Control/Family Planning

• Decision by woman and partner

• Consider culture, religion, and economics

• Availability

Contraception

• Barrier method - condom, spermicidal gel or foam

• Hormonal contraception

  • Progestin-only for BF moms and estrogen-progestin contraceptives okay for nonlactating moms, not ideal for BF (reduce quality and quantity of milk; if must start, wait until BF is established, 6 weeks)

• Plan to begin after 6 weeks

• *Ovulation occurs before menstruation; therefore, BF is not a reliable method of contraception

Postpartum - When to Call the Doctor

• PP blues lasting more than 2 weeks

• Heavy bleeding

• Large clots

• Fever

• Odor

• Redness or pus from incision

• Pain

• Frequent urination

• Questions or problems

Neonate vs. Infant

• Neonate - birth to 28 days

• Infant - under 1 year of age

• Neonatal transition - occurring the first few hours of life

Newborn - Respiratory

• Fluid filled > air filled

• Surfactant: a surface-active phospholipid critical for alveolar stability

• L/S (Lecithin and Sphingomyelin) ratio of 2:1 is more evident in 35+ GA infant

*Early = immature lungs = respiratory issues

*C/S = suction

Newborn - Reflex Breathing Triggers

• Cord clamped and cut (causes chemical changes):

  • Low blood oxygen levels

  • Increased blood carbon dioxide

  • Low blood pH

• Temperature changes

  • Decreased in hospital

• Drying (with blanket; sensory)

*Crying = breathing

Newborn - Respiratory Rate

• Normal 30-60/min

• Apnea more than 20 seconds is abnormal

• Periodic breathing (pause) lasting 5-15 seconds

• Nose breathers

  • Obstruction = suction

  • Bulb syringe = don’t overuse (causes inflammation of mucous membranes)

Newborn - Circulatory Changes

• First breath closes the following shunts:

  • Forman ovale

  • Ductus arteriosus

  • Ductus venosus

• Murmur, not symptomatic, <24 hours = is okay

• >24 hours, murmur, cyanosis (lips) = not okay

Newborn - Heart Rate

• Normal 110-160

• Apical Pulse 1 full minute (for RR + HR)

• Murmurs

• BP 50-75 mmHg systolic and 30-45 mmHg diastolic

  • Don’t take in a newborn

Thermogenesis

• Heat production

• Normal temperature - 97.7-99.5

• Newborns have trouble with maintaining normal temperature due to excessive heat loss rather than impaired heat production

• Heat is produced by:

  • Shivering

  • Non-shivering

    • Brown fat (vascular fat; see picture for location)

    • Baby’s don’t shiver

• Keep baby warm on moms chest (skin to skin)

*Axillary temperature first (rectal temps damage tissue)

Sites of Brown Fat

• Midscapular area

• Around neck

• Axilla

• Around trachea

• Esophagus

• Abdominal aorta

• Kidneys

• Adrenal gland

*Can be broken down = cold stress occurs

Newborn - Heat Loss

• Convection

  • Exposure to cool air currents (positioning)

• Radiation

  • Exposure to cool objects near infant (outside wall)

• Evaporation

  • Wet body surface

  • Remove fluid after delivery asap

  • Spit up = change clothing

  • Wait for first bath (8-12 hours); cover baby where not bathing during bath

• Conduction

  • Cool surface exposure on infant (cold clothes, towels, stethoscope)

  • Scale - use covers

*Don’t overheat baby = increased risk of SIDS (1 extra layer than us, hats outside only)

*Assess temperature last

Cold Stress

Excessive heat loss resulting in compensatory mechanisms (increased respirations and non-shivering thermogenesis) to maintain core body temperature

Newborn - Digestive

• Reflexes

  • Suck + swallow (term)

• Enzymes

• Stomach capacity

• Bowel sounds

  • 1st 30 mins-hour of life

• Stool-meconium

*Premature = feeding issues

*Over feed = spit up (bottle)

Newborn - Stools

• 1st day = 1 pee and 1 poop and so on

• Pee, poops, and gaining weight = adequate nutrition

• Breastfed babies

  • 6-10 small, semi liquid yellow stools per day by 3rd or 4th day after milk production is established

  • Seedy = broken down protein

• Formula-fed babies

  • 1-2 stools per day, more formed, yellow or yellow brown

• Meconium stool

• Transition from meconium, brown to green

Newborn - Urination

• 6-8 wet diapers per day

• Should have first urination in first 24 hours of life

Bilirubin

• Broken down RBCs

• Conjugated (direct) - conversion of yellow pigmented fluid into a water-soluble pigment

• Unconjugated (indirect) - breakdown of hemoglobin from RBCs = liver = excretable form (supposed to)

  • Not an excretable form and a potential toxin

  • Deposits in tissues = jaudice

• Total = sum of both = <3 mg/dL = normal (low due to mom, increased after cord clamped)

Physiologic Jaundice

• Acceleration of destruction of RBCs impaired conjugation of bilirubin; not pathological normal variation of newborn

  • Imbalance between the production and elimination of bilirubin

    • Babys liver has to “catch up” = levels increase after 1st 24 hours

  • 60% of FT and 80% pre-term babies on 2-3 day

Pathologic Jaundice

• Occurs within the first 24 hours (underlying condition → infection)

  • Needs hydration, warmth, monitor for adequate stools, early feedings, phototherapy

Breastfeeding Jaundice

Rise after the first 24 hours; need to increase number of feeedings

Measurement of Bilirubin

• Bilimeter

• Blood test → heel stick (most accurate)

*Turn yellow in face first

Bilirubin Levels in Newborns

• Based on age ond levels

• Low risk zone (no interventions)

• High risk zone (when bilirubin deposits in tissues = deposits in brain (kernicterus); interventions like phototherapy)

Phototherapy

• Assessments:

  • Temperature

  • Skin

  • RR

  • I+O’s → make sure excreting bilirubin

• Functions as liver (photobili)

• Pathologic jaundice = treat underlying cause (like infection)

• Eyeglasses

Newborn - Integumentary Color

• Pallor (when 1st born)

• Pink

• Jaundice

• Cyanosis

• Acrocyanosis (blue in hands and feet; take minutes to hours to subside; normal)

Newborn - Laungo

Fine hair (decreased in term babies) → vernix caseosa keeps on

Newborn - Milia

Plugged glands (leave alone)

Newborn - Telangiectatic Nevi

“Stork bites” → fades

Newborn - Erythema Toxicum

• Newborn rash

• Goes away on its on; due to sensitive skin

Newborn - Mongolian Spots

• Darker skin spots

• Common in lower back and buttocks

Newborn - Vernix Caseosa

• White cheese (protects from amniotic fluid + infection)

• Keep on baby till 1st bath

Common Reflexes of the Newborn

• Tonic neck

• Palmar grasp (hold hands)

• Planter grasp

• Moro (“starle”)

• Root

• Suck

• Step

• Babinski (stroke bottom of foot = toes fan outwards)

APGAR

• Assessment after birth, warrants interventions

• Perfect score: 10 (1st min),10 (5 mins)

• < 6 is a concern

Newborn - Physical Assessment

• Vital signs (temperature last)

• Cry

• Measurements

• Head

• Neck

• Skin

• Face

• Chest

• Abdomen

• Extremities

• Genitalia

Newborn Measurement

• Not a priority due to golden hour

• Weight

  • Average is 3405 g (7 lb 8 oz)

  • Range 2500-4000 g (5lb 8oz - 8lb 14 oz)

• Length

  • Average 50 cm (20 in)

• Head circumference (largest part of body)

  • 33-35 cm (13-14 in)

• Chest circumference

  • Average 32 cm (12.5 in)

Newborn - Head/Neck

• Molding

  • Sutures overlap = cone head = fit in birth canal

• Cephalhematoma

  • Blood/fluid in head

• Caput Succedaneum

Newborn - Face/Eyes/Ears

• Symmetry

• Eye color established 3 months

• Eyelids edematous during first few days of life

• Nose: small and narrow

• Mouth: lips pink

  • Saliva scant

  • Epstein’s Pearls (white matter)

  • Thrush

• Ears: top of ears (pinna) should be parallel to the outer and inner canthus of the eye

Newborn - Abdomen

• Should be cylindrical, protrude slightly, and move with respiration

  • Preterm = protudes/concaves

• Auscultate bowel sounds before palpation

Newborn - Umbilical Cord

• White and gelatinous

• Cord bleeding is abnormal

• Assess for infection

• Umbilical hernia

• Cord begins drying 1-2 hours after birth (shrivels and blackens by 2nd or 3rd day)

• AVA

  • 2 arteries

  • 1 vein

Newborn - Genitalia

• Male

  • Hypospadias

  • Cryptorchidism

  • Hydrocele (fluid in scrotal sack, resides on own or drain)

  • *Swollen when first born due to increased levels of female hormones

• Female

  • Pseudomenstruation (false period)

  • Smegma (think white substance, protective, don’t remove

Hydrospadias

Urethra not at tip of penis (warrants surgery)

Cryptorchidism

• Testicles don’t descend into scrotum

• Expected in preterm; term → infertility (surgery)

Newborn Maturity GA

• Preterm

• Term

• Post term

• Dubowitz or Ballard Scale Rating and Classification

SGA

Small of gestational age; weight less than the 10th percentile (usually <5.5 lb)

AGA

Appropriate for GA, between 10th and 90th percentile

LGA

Large for GA; more than the 90th percentile (usually >9lbs or anything greater than 4000g)

• Glucose (decreases once cord is cut; >40 is normal)

Newborn - Physical Maturity

• Skin - leathery, cracks, veins, visible

• Plantar surfaces - creases over sole

• Breast - nodule and areolar area

• Ear - pinna

• Male genitals - scrotum, testes, rugae (wrinkles → less in preterm)

• Female genitals - clitoris, labia majora, labia minora

Newborn - Immediate Care

• Maintain clear airway

• Thermoregulation

• Medications

  • Vitamin K (AquaMephyton) IM → promotes blood clotting

  • Erythromycin (antibiotic opthalmic ointment) → prevents infection that would cause eye issues

  • Hepatitis B vaccine

• Initiation of first feeding (15 finger feed drops = feed)

• Parent-newborn attachment

IM Injection Newborn

• LEG ONLY

• 25 G needle

• Vastus lateralis

Neonatal Distress

• Retractions

• Nasal flaring

• Grunting

• Facial grimacing

• Cyanosis

• Abdominal distention

• Vomiting

• Jitteriness (BG < 40)

Ongoing Newborn Care

• Thermoregulation

• Nutrition

• Suctioning (bulb syringe)

• Safety

  • General

  • Hospital safety

  • Care seat

  • SIDS

• Circumcision (due to risk of infection + cancer)

• Bonding

• Care of baby

• Newborn screening and immunizations

  • Screening - “PKU”

    • Helps detect disorders

    • Some feedings on board before hand

• Sleep

Nutritional Needs of Newborn

• 105-108 kcal/kg/day

• Formula (fat content unchanged) fed babies gain weight faster than breast fed babies

• Lose weight in first 3-4 days (no fat in BM, loose 10% of birth weight)

• Weight gain about 10g/kg/day or 5-7 oz./week

• BM is digested more easily

  • Milk produced is exactly what the baby needs (whether full or preterm)

Signs of Dehydration in Newborn

• Depressed fontanelles

• Rapid, weak pulse

• Elevated low-grade temperature

• Dark, concentrated urine

• Dry, hard stool

• Number of changed diapers decreased

• Dry skin with little turgor

• Elevated specific gravity (1.020)

How does the breast make milk?

• Ducts and alveoli grow during pregnancy under influence of progesterone and estrogen (also same hormones that make breast milk)

• Small amounts of colostrum (1st milk; antibodies, laxative), 1-2 teaspoons), per feed (small stomachs, size of a marble, + frequent feeds)

• Delivery of placenta triggers hormones prolactin and oxytocin

• Prolactin-produces milk

• Oytocin-milk let down reflex (ejection of milk)

• Stimulation of breast (increased stimulation = more milk; pumps while in NICU)

• The more often the breast is emptied, the more milk is made (supply and demand)

Interference with Milk Supply

Anything that interferes with growth of alveoli and ducts, progesterone levels, or other hormone levels, or breast stimulation

• Some women don’t stimulate enough milk

• Breast surgery? (yes, no if reduction/cancer (+meds))

Colostrum

• First milk

• Yellowish creamy fluid

• Thicker than milk

• Contains: low fat, high protein, fat-soluble vitamins, minerals

• Coats and protects baby’s digestive tract

• Laxative effect

• Passive immunity

• Develops during pregnacy lasting several days after delivery

Transition Milk

• Day 3-4 → weeks

• Soft → firm breasts

• Produced from end of colostrum until 2 weeks postpartum

• Changes appearance and composition

• Contains: more fat, sugar, vitamins, and calories

Mature Milk

• Look thinner and more watery than cow’s milk

• White, can be slightly blue-tinged in color

• Foremilk (“appetizer”) - beginning of feeding contains more water, less fat higher lactose

• Hindmilk (“entree”) - higher fat content

• 20 kcal/oz

• Recommended for first 6-12 months of life

---

• Don’t watch the clock when feeding

  • Feed q2-3 hours

• Always offer other breast to baby, then start with that breast next feeding

Golden Hour

• 1st hour of baby life → wide awake → recovery sleep (18-24 hours)

• Baby alert and ready to fedd within 1-2 hours after birth

• Optimum place for baby to recover from birth is skin to skin on mothers chest (BG stable, warm, RR stable)

• Baby will instinctively root and seek out breast

• Recovery sleep

Advantages of Breast Milk

• Inhibits bacteria growth

• Easy digestion of lactose, lipids, fatty acids, amino acids

• Varies in content and need of newborn

• Helps with maternal-newborn attachment

• Convenient, safe, and free of cost

Disadvantages to Breastfeeding

• Medications passed from mother to newborn (antidepressants)

• HIV or AIDS of mother (No BF; common to BF in third world countries d/t lack of water, clean bottles)

• Excludes the father (mothers can pump)

• Working mothers

Position + Latch

• 1) moms in a comfortable position (bring baby TO breast, not breast to baby)

• Hamburger latch (wide mouth then latch; milk not just at nipple, need as much breast tissue as possible)

• Prevents sore nipples and cracked nipples

• Allow efficient milk transfer

Signs of an Effective Latch

• Mouth open wide

• Lips flared outward

• Large amount of areola in mouth

• Ear and jaw moving

• Actively sucking and swallowing

• Mom feels strong tug on breast, not painful

Signs of an Ineffective Latch

• Mouth not open wide

• Small amount of breast in mouth

• Clicking/smacking sounds

• Painful

• Common cause of sore nipples