Maternity Exam 1

Postpartum nursing care

-assess for early signs of potential complications

• is anything going wrong; assessing until goes into stable timeframe of about 48 hours

-maintain safety

-promote health

-educate families

-postpartum - from birth until everything returns to normal, returns to normal in ~6weeks

Postpartum Vital Signs

-monitored frequently every 2/3 hours; Q4 first 24-48 after birth

-Normal vs. abnormal

• temperature is same

• HR slightly high

• RR and BP same

• above 140/90 Bp is abnormal

-Pain

• pain assessment- usually 0-10 scale; OLDCARTS

  • need to know type of delivery when assessing

• common causes

  • afterbirth pains- uterus cramping afterbirth to stop bleeding

  • incisions, back and leg pain

  • headaches (RED FLAG- preeclampsia)

• treatment

  • **pharmacologic-

    • ibuprofen- 600 mg PO q6hr

    • acetaminophen- 650-1000 mg PO q4-6h

    • oxycodone (c/s usually)- 5-10 mg PO q4-6hr

  • nonpharmacologic- ice packs/heat, sits bath, decrease light/noise, pillows

Postpartum Assessment

-B- breast

-U- uterus

-B- bladder

-B- bowels

-L- lochia

-E- episiotomy, lacerations, incision

-E- extremities

-E- emotions

Postpartum Assessment: Breasts

-increased prolactin creates milk production

• colostrum in first few days for newborns- densely packed with nutrients and fat

• colostrum → mature milk with volume increases over time and growth

• filling stage: with mature milk change, breasts fill and become warm, firm, and tender

• engorgement phase: venous and lymphatic congestion as milk comes in (body must learn to regulate how much to make so breasts become filled, huge, and uncomfortable); hormone shift

  • ice, frozen cabbage leaves (anti-inflammatory)

Nursing Care: Breast Feeding vs Not

-assess breastfeeding and breasts and nipples

• intact, no redness, skin breakdown, assess latch score

-patient education

• supportive bra- for chest and back muscles

• nipple care- breast milk onto skin, lanolin (moisture barrier to keep skin healthy, not raw, baby safe

• engorgement relief- breastfeed to relieve pressure or low amounts of hand expression; ice after feeds

-if not breast feedings, assess breasts but avoid palpation

• without stimulation, prolactin levels drop rapidly

• fluid shift still occues (some engorgement and colostrum may be present)

-patient education

• supportive bra

• avoid nipple stimulation and milk expression

• ice for engorment

Postpartum Physiology: Cardiovastular and Respiratory System

-cardiovascular

• blood volume: increases prenatally in anticipation of blood loss in pregnancy

• Quantified/Estimated blood loss (QBL, EBL)- up to 500 mL for vaginal birth and 1000 mL for c/s birth of blood loss

• orthostatic hypotension- lower fluid levels

• postpartum chills- cold but shaking. sweating profusely

-respiratory- everything should return to normal

• postpartum edema

Postpartum Care: Cardiovastular and Respiratory System

-assess Hgb and Mct

• anemia: *** Hgb <11 and Hct <32

• if low, given ferrous sulfate PO

• blood transfusion if sympromatic or severe

-orthostatic hypotension safety- change position slowly, sit at bed side and dagnle, stand up and stay still to avoid dizziness

-pospartum chills comfort- warm blanket, drinking warm drinks

-encourage deep breathing and coughing in post-op patients

-assess for venous thrombosis (DVT as high estrogen increases chances)

Postpartum Physiology: Uterus

-want uterus to cramp down to cause involution (uterus back down to size from pre-pregnancy which takes ~6 wks)

• uterine contracitno and atrophy

-subinvolution- uterus fails to return to non-pregnant state

• blood vessels in uterine muscle bleeding → postpartum hemorrhages

• causes:

  • retained placenta

  • infection- inflammation and bleeding caused

  • atony- uterus does not cramp from meds, multiple births, large uterus stopping it, etc.

-To assess: lower HOB and support LUS (lower uterine segment) with straight down pressure

• start high- inch above belly button

• right after birth: fundus is FF u/u- uterus even with belly button

  • 12hrs after- either FF u/u or FF 1/u (1 cm above uterus)

  • few days, should go down and get smaller FF u/1

  • should see 1-2 cm per day after birth; do not want to be higher than expected or go backwards

• assessing for

  • height

  • tone- smooth ball

  • midline or deviated- should be midline

  • tenderness- not lots of pain, some crampy normal

-Care: oxytocin (endo and exo genous), fundal massage, pain management

Postpartum Physiology: Abdomen

-diastatis recti- separation of abdominal muscles outward

• expected immediately postpartum

• should be close to normal at postpartum visit

• without healing, need PT or surgery to close gap

Postpartum Care: Incision

-Assessing- REEDA

• redness- sign of infection

• edema- sign of bleeding

• eccymosis

• drainage- sign of infection or hematoma

• approximated (closed?)- don’t want incision to pull apart

-incision care- promote healing

• pat dry to reduce infection, fluid, warm soapy water run over it, rest, healthy diet

-linea inegra- hormone related in prgnancy; vertical line of hyperpigmentation along belly button

• sometimes stays, worsens, or goes away

Postpartum Assessment: Bladder

-physiology

• risk for retention- decrease in bladder sensation to void

• postpartum diuresis- 12-24 hrs lots of pee from fluids and hormone shifts

-assess

• urination- need to be peeing

• foley catheter care- monitor UTI signs

• straight catheter insertion if needed

• teach proper wiping (front to back)

• Kegel exercises to help strengthen pelvic floor

Postpartum Assessment: Bowels

-physiology

• dietary changes- hungry

• risk of constipation- decreased motility

• hemorrhoids- common assess and give meds as needed

-assess GI system

• regularity, pain, consistency

  • docusate- stool softener

• fluid intake and diet

Postpartum Assessment: Lochia

-lochia- bleeding that occurs after delivery

-Types

• lochia rubia- bloody, red; scant to moderatel; increases with standing and breastfeeding

  • abnormal: large clots, heavy bleeding, foul odor

  • 1-3 days

• lochia serosa- light red/pink; scant; increase with physical activity

  • abnormal- heavy amounts; foul odor

  • 4-10 days

• lochia alba- yellow/white; scant

  • abnormal- bright red; foul odor

  • 10 days- 6wks

-Assessing

• scant: only when wiping, <1 in on pad

• light/small- pad 25%; 1-4 in

• moderate- pad 50%; 4-6 in

• heavy- pad saturated

  • assess fundus! massage uterus; emergency chain

Postpartum Physiology: Perineum

-edema with vaginal deliveries

-pelvic relaxation- Kegel exercises to help

-lactation decreases estrogen

• mucosa atrophy- dryness and decreased lubricaiton expected

-Nursing Care- REEDA

• assess area

• comfort measures- ice, sitz bath, medications

• educate- padding laceration, change pads frequently, peri bottle

Postpartum Assessment: Exteremities

-assess

• peripheral edema

• signs of DVT

• joints

• IV site

-educate for increased risk of thrombosis

• signs of DVT: pain, redness, one leg swollen

Postpartum Assessment: Emotions and Bonding

-emotional status

• taking in

  • immediately postpartum- first 24-48 hours

  • dependent on others for own and baby’s care

  • focus on pain, need reminds of care- showers, breastfeedings, change pads

• taking hold

  • demonstrate increase in independence in care

  • take care of self more, ask questions, process education

• bonding

-fatigue- encourage rest and self-care as much as possible

-Baby Blues- shifting hormones → emotional instability

• still take care of baby, short term (2-4 wks postpartum)

• causes: hormal changes, fatigue, stress

• encourage its normal and short-term

• no other interventions unless goes past short time frame and ability to cope/take care of baby fails (postpartum depression)

Postpartum Physiology: Endocrine

-rapid decrease in placental hormones reverses insulin resistance

-estrogen decreases→ diaphroesis

-ovulation and menses

• non-lactating- 7-9 wks

• lactating (breastfeeding)- 6 months if exclusive

• first menses usually heavier, then normal flow

Postpartum Physiology: Integumentary

Pictures on Slides!

-hyperpigmentation

• melasma disappears

• linea nigra and areolar changes stay

-spider angiomas may disappear

-striae gravidarum fade

-temporary hair loss

-itching

• postpartum hives

Postpartum Care: Immunizations

-MMR- in non-immune rubella or equivocal

• subcut

• side effects- transient arthralgia, rash, fever

• no one with egg allergy, immunocompromised family members

• avoid pregnancy x4wks; cannot be given during pregnancy

• informed consent

-Tdap if not given during pregnancy; should get with each pregnancy to benefit child

-Flu shot and covid- help protect baby

• all helpful for antibodies can be given to baby via placenta or breastfeeding

-Rhogam- Rh Immunoglobulin

• antibodies to Rh antibody

• *dosage- 300 mcg IM or IV within 72hrs

• only if mom is Rh- and baby Rh+

• clears mom’s system of positive blood to stop antibody creation that could hurt future babies

Transition to Extrauterine Life: Respiratory