maternal exam 4 set 2

operative birth

• not a complication

• intervention to aid fetal descent or expedite birth in response to complications

• use of forceps or vacuum extractor

potential maternal complications of operative birth

• tissue trauma

• increased pain

• hemorrhage

• postpartum incontinence

potential fetal/newborn complications with vacuum extractor

• cephalohematoma

• intracranial hemorrhage

• scalp laceration

• brachial plexus injury

potential newborn complications with forceps

• facial lacerations

• facial nerve palsy

• ocular trauma

• skull fracture

• intracranial hemorrhage

clinical presentation for operative birth

• inadequate pushing/exhaustion

• maternal medical conditions

labs/diagnostics for operative birth

• size/shape of pelvis- ultrasound

• cervical dilation, fetal position

• membrane status, fetal weight

tx/therapies for operative birth

• positioning, team members

• pain management

• fetal assessment during and after birth

prolapse cord

• OB emergency

• cord may be visible with vaginal exam

• if membrane is intact, may prevent presenting part from being observed

clinical presentation of prolapse cord

• fetal heart tracing

• prolonged decel

• fetal bradycardia

• recurrent variable decels

tx and therapies for prolapse cord

• initiate OB rapid response

• emergent birth

• keep presenting part off cord using 2 fingers

• positioning, O2 via face mask

• sterile fluid infusion into bladder

action plan for prolapse cord

• fetal presenting part elevated with sterile gloved hand

• rapid response team, oxytocin discontinued

• reposition client, monitor FHR

• apply O2 if prescribed

• insert IV and indwelling cath, instill fluid into bladder as prescribed

shoulder dystocia

• OB emergency during vag birth, can be life threatening, cause anxiety

• turtle sign- head goes out, then in, then out

risks for shoulder dystocia

• prior history, obesity

• macrosomia, male gender

• epidural, prolonged stage 2

action plan for shoulder dystocia (CAMPEER)

• C- call for help

• A- apply suprapubic pressure

• M- movement of fetal arms across the head to dislodge shoulder

• P- position the client onto their hands and knees

• E- prepare for episiotomy

• E- elevate the legs to a knee-chest position

• R- rotation of fetus manually

maternal considerations for shoulder dystocia

• breathing techniques, patient edu

• repositioning, soft tissue injury/pain from episiotomy

• hemorrhage, nerve damage, uterine rupture, bladder lacerations

• newborn- brachial plexus injury of erb duchenne palsy

feeding care

• 8-12 feedings/day every 2-3 hrs for newborns, 15-20 min per breast

• postpartum assessment of breasts/nipples

breastfeeding care

• inspect/palpate- soft, foling, firm, engorged

• primary engorgement- first 72 hrs, related to tissue edema

• secondary engorgement- if feeding decreases it can ocur

• inspect nipples for redness, pain, erectness, and crack

breastfeeding and latching

• recommended for 6 mo for immunity and bonding

• latch should be wide and deep, should be no pain

• effective: 3 bms, 6-8 wet diapers in 24 hr after day 4

reduce breast stimulation when patient does not want to breastfeed

• cold compress or cold cabbage leaves in bra

• well fitted shirt and bra

• no stimulation

steps of newborn latching

• lips around nipple and most of areola (wide and deep)

• newborns abdomen should be flat against mom, head and neck should be in alignment

• newborns chin under breast and wait for them to latch

• newborns nose should be free, chin buried

bottle feeding/formula

• supplement insufficient breast milk, safety, maternal client returning to work, increasing body weight, adoptive parents, maternal rest

• feed every 3-4 hrs, 15-30 min per feeding

• burp every ½ oz or so, may have to wake during feedings

• infants head should be slightly elevated (15-20 degrees)

• look for hunger cues, not emesis

postpartum infections

• puerperal infection endometritis

• mastitis

• wound infections

• sepsis

• often strep a/b or e coli

mastitis

• F- fever

• A- abnormal appearance of milk

• S- swelling sensation/burning, salty flavor of milk

• T- tenderness, redness of breast

• massage, warm compress, pump and feed to get any stasis out, meds

endometritis

• infection of uterine lining

• most common

• IV broad spectrum antibiotics therapy

wound infections postpartum

• after discharged

• after C section

• culture and treat

newborn assessment

• APGAR at 1 min and 5 min, PRN after

• temp regulation

• general appearance, posture

• resp, cardiac, neuro, eye/nose/mouth, and skin assessments

postpartum assessment of mom

• frequent vitals

• fundal position and consistency (NO BOGGY, massage)

• urinary elimination and bladder distension

• assess lochia and perineum

postpartum assessment of mom vag birth post anesthesia

• activity, respirations

• BP, LOC

• sensation/movement of extremities

postpartum assessment of mom C section post anesthesia

• activity, respirations

• BP, LOC, orientation

• skin and surgical site

• READA: redness, edema, ecchymosis, discharge, apposition/sides together and aligned

perineal care after delivery

• pain management

• cold therapy using ice (10-20 min at a time)

• tucks pads (cooling pads), topical meds

• perineal squirt bottle for cleaning

• stool softeners

• muscle strengthening exercises

sitz bath for perineal care after delivery

• treats pain and inflammation, promotes healing of tissue and manages hemorrhoids

• cool water for inflammation/discomfort

• warm water to promote circulation and relieve pain/relax muscles

new born reflexes

• sucking, rooting (turns to stimulation)

• tonic neck (turns head to side when lying on back)

• moro, grasping

• babinski (toes curl upward when you apply pressure to their foot, is gone by 2 yr)

5 P’s related to preparing for birth

1- power of contractions

2- passenger, position of fetus

3- passegway, maternal pelvis

4- position, maternal position

5- psyche, mental and emotional status

placenta cardinal signs for delivery

• globular fundus (contracts like fist)

• gush of blood

• cord lengthens

preterm labor

• regular uterine contractions that cause cervical changes prior to 37 weeks

• treat underlying cause (infection, dehydration, etc)

postpartum hemorrhage

• urterine atony- marked hypotonia of uterus, inadequate uterine contraction occurs, uterus remains flaccid

• 1000+ mL blood loss

• primary- within 24 hrs, secondary- after 24 hrs up to 6 wks

• weigh pads if concerned

maternal physiological adaptations

• cardiac output back to pre-labor within 1-2 hrs postpartum

• HGB over 11 and HCT over 33%

• blood volume loss over 1000 mL is PPH

• postpartum diuresis- urinate up to 3000 mL

subinvolution

failure of uterus to return to its pre-pregnancy state

PKU

collect after 24 hr of nutrition/beast milk

thermoregulation- convection

heat loss by air or water moving across the skin

thermoregulation- evaporation

body heat turns sweat into vapor

thermoregulation- radiation

bare skin is exposed to an environment containing objects of cooler temp

thermoregulation- conduction

direct contact with an object

mongolian spot

dark spots on the skin, normal

acrocyanosis

pink body but hands/feet cyanotic, normal

vernix

white cheesy stuff covering at birth

lanugo

body hair, more if preterm

milia

little white spots, pimples

erythema toxicum

rash due to adjusting to outer environment

jaundice

• yellowing

• first 24 hrs pathological, not good

• day 2-3 is physiological and generally expected

• phototherapy, no lotion

• track with TCB or heel stick