Exam 3 maternal

prevent hemorrhage

main goal during the immediate postpartum period

hemorrhage, shock, infection

greatest risk in postpartum patient

involution

reduction in size of the uterus after delivery to nonpregnant size and condition
-occurs with uterine contractions, catabolism, regeneration of endometrium (exfoliation)

factors that help involution

uncomplicated delivery, breastfeeding, early ambulation, complete expulsion of placenta

factors that slow involution

prolonged labor, anesthesia, gran multiparity, retained placental fragments, FULL BLADDER, infection

fundus

top of the uterus
DESCENDS ABOUT 1CM (fingerbreadths per day)
non-palpable after 14 days

subinvolution

the delayed return of the uterus to its nonpregnant size & consistency
-boggy uterus, above the level of normal decent, bleeding/hemorrhage

documentation

location of uterus related to umbilicus, tonicity of uterus

ex: firm midline 2+U

interventions for boggy uterus

void, reassess the fundus, massage

lochia

vaginal discharge of blood & debris following delivery
(1) lochia rubra 1-3days -red
(2)lochia serosa 4-10days -pink
(3) lochia alba 11-28 days - yellow/white

-no clots larger than a nickel; unexplained increase or return of lochia rubra is NOT NORMAL!!
-NO SATURATING PAD IN 15 MIN\= HEMORRHAGE

1 G \= 1 ML BLOOD

500\> mL

EBL for vaginal delivery

no more than 1,000mL

EBL for C-section delivery

urinary changes

↑ bladder capacity & ↓ bladder tone lead to ↓ sensation & ↑ risk of Urinary retention/infection
-2,000 to 3,000 mL
-FULL BLADDER DISPLACES UTERUS
*HAVE PT VOID THEN REASSESS FUNDUS

signs of distended bladder

fundus above baseline or displaced from midline, excessive lochia, bladder discomfort, bulge of bladder, frequent voidings <150mL

RhoGAM within 72hr after delivery

if mom is Rh- and baby is Rh+ then mom will need

(negative indirect coombs' test)

rubella

mom needs vaccine if she does not have positive titer
MUST AVOID PREGNANCY FOR AT LEAST 1 MONTH, PREFERABLY 3 MONTHS AFTER VACCINE
**CONTAINS LIVE VIRUS; teratogenic to baby

BUBBLE-HEB (postpartum assessment)

breasts, uterus, bladder, bowel, lochia, episiotomy/lacerations, Homan's sign, emotional status, bonding

pp temperature

initially elevated after delivery r/t dehydration & exertion
ABOVE 100.4 FOR 2 CONSECUTIVE DAYS (EXCLUDING 1ST 24HRS) IS SIGN OF BEGINNING PUERPERAL INFECTION

bonding

describes initial attraction felt by parents for their infants; enhanced when not separated 1st hour after birth

attachment

process by which an enduring bond between a parent/child is developed
ENCOURAGE BABY ROOM-IN TO HELP FACILITATE

phases of maternal adjustment

(1) taking in phase (1st 3 days pp)
(2) taking-hold phase (3-10day pp)
(3) letting-go phase (10days-6wk)

factors affecting adaptation to motherhood

-lingering pain
-chornic fatigue
-knowledge of infant needs
-expectations of the newborn
-previous experience with infants
-maternal temperament
-infant characteristics
-support system
-CSection, preterm/ill baby, birth of multiples

postpartum blues

transient depression usually occurs between 2-3 days PP or within 1st 2wks PP
-mood swings, anger, tearfulness, feeling let-down, anorexia, insomnia
-resolves spontaneously, evaluation needed if persistent or severe

oxytocic medications

prevents hemorrhage
Oxytocin (Pitocin), methylergonovine maleate (methergine) ergonovine maleate (Ergotrate)

s/e: hypotension w/ rapid IV bolus of Pit
HTN w/ methergine or ergotrate

perineal care

IMPORTANT FOLLOWING EPISIOTOMY
-squirt, pour warm water over perineum
-blot dry front to back to prevent tissue trauma or contamination
-apply clean peri pad front to back

*wash hands every time peri pad is changed, do not flush toilet while sitting

true

t/f: a nurse must assist pt up to the toilet 1st time out of bed and to 1st shower

500kcal/day

lactating mothers should add \____ to the pre-pregnancy diet

episiotomy has healed & lochia has stopped

couple can resume sexual activity after the

surfactant

lines alveoli; detected 24-25wk gestation
↓ surface tension to keep alveoli open
↑ during labor & immediately after birth to prepare baby to breathe outside of womb
sufficient amount @ 34-36wk
steroids given in preterm labor to ↑ production & lung maturity

thermoregulation (dry baby with blanket; skin to skin w/mom)

priority nursing intervention post-delivery

evaporation

insensible h2o loss from skin
-air drying skin
ex: wet diaper, vomiting on clothes, hair wet
*DRY IMMEDIATELY AFTER BIRTH W/WARM BLANKET

conduction

cold surfaces
-loss of heat to a cooler surface by direct contact
ex: cold hands, stethoscope, cold scales
*WARM OBJECTS WILL TOUCH NEWBORN; ENCOURAGE SKIN TO SKIN; PLACE BARRIER ON SCALES

convection

from cool air
-circulating air in room (air conditioner; open door)
*PREVENT DRAFT IN ROOM, PLACE INFANT AWAY FROM CURRENT, USE NASAL CANNULA FOR 02; STOCKING ON HEAD; CLOSE DOORS

radiation

from surrounding cooler objects
-transfer of heat to cooler objects that are not in direct contact with infant
ex: cribs by window, body touching crib/incubator
*USE OF RADIANT WARMER

non-shivering thermogenesis

↓ in core temp will not occur until \___ is no longer effective
-if a baby shivers they have been cold for a while

brown fat

**CAN INCREASE HEAT PRODUCTION BY 100% WHEN METABOLIZED
-located on back of neck, axillae, b/t scapulae, along abd aorta, adrenal gland & sternum

s/s of cold stress

restlessness, crying, ↑ in body flexion & activity

Acrocyanosis

bluish discoloration of hands & feet
-normal finding
-a physiologic response to cold
-indicator of resp distress

o2 & glucose demands

body metabolism increases require ↑ in

89.6-92.3F

environmental temp range for unclothed baby

75.2-80.6F

environmental temp range for clothed baby

factors affecting the blood in baby

time of cord clamping, position of the infant when clamped & gestational age

location of blood draw on baby

heel sticks
*SHOW HIGHER H&H LEVEL R/T SLOW BLOOD FLOW

vitamin k

born with low levels
given to prevent deficiency bleeding
one IM dose w/in 1st hour; can be delayed until after breastfed

6ml/kg

capacity of stomach is about \____ at birth

newborn intestines (*)

STERILE at birth
-longer in proportion to newborn's size compared to adult
-pros: allows for more absorption
-cons: effects of dehydration greater with diarrhea
-bowel sounds present in 1st hour

pancreatic amylase

is in deficit for 1st 4-6 months after birth
needed to digest complex carbohydrates

meconium

-1st type of stool expelled by newborn
-characteristics: greenish, black, thick, sticky, tarlike
-usually passed w/in 12 hours
-99% of newborns pass w/in 24 hrs
-not passed within 48hr \= suspect bowel obstruction

glucose level

-1st 1-2 hours after birth can be as low as 30mg/dL
-day 1: 40-60
-normal after first day 50-90
-hypoglycemia <40-50
*FEED BABY IF STILL S/S LOOK INTO GLUCOSE IV

jaundice

liver helps break down bilirubin to remove it in stool
-occurs in 60% of term babies & 80% preterm
-after birth, less RBCs are needed than in utero

bilirubin

yellow substance body created when replacing old RBCs; TOXIC TO THE BLOOD AND NEEDS TO BE EXCRETED

**jaundice occurs when absorbed in SQ fat causing skin to turn yellow

indirect (unconjugated) bilirubin

not water soluble; body cannot excrete it

conjugated (direct) bilirubin

liver has converted into water soluble form; it is not toxic in this form and is removed via the small intestine in bile

bilirubin encephalopathy

acute; accumulation of bilirubin in brain tissue

kernicterus

chronic; permanent neurologic injury to brain and body due to bilirubin

total serum bilirubin (TSB)

sum of conjugated and unconjugated bilirubin

physiologic jaundice

*not usually concerning
-occurs after 1st 24 hours & peaks 3-5 days
-caused by hemolysis of RBCs & liver immaturity (no underlying liver disease)
-50-60% of all newborns in 1st week of life
-visible when TSB is 5-6mg/dL

non-physiologic (pathologic) jaundice

DANGER!!
-begins during 1st 24hrs or lasts more than 1 week
-bilirubin rises faster than 5mg/dl in 24hr
-caused by destruction of RBCs or problems w/ bilirubin conjugation, incompatibilities in blood types, infection metabolic disorder
-tx phototherapy

early onset jaundice

associated with breastfeeding
-early onset: occurs by 1 wk age
-caused by insufficient intake r/t sleepy, poor suck reflex, infrequent nursing, did not receive enough colostrum
-TSB can ↑ above 12mg/dL

tx: monitor TSB; 8-12 feedings in 24 hrs, phototherapy for high levels, formula feedings 1-3days while mom pumps

true breast-milk jaundice (late-onset jaundice)

after 3-5 days of life and lasts 3 weeks-3 months
-unknown cause
-TSB peaks at 5-10mg/dL; falls over several months

tx: monitor TSB; 8-12 feedings in 24 hrs, phototherapy for high levels, formula feedings 1-3days while mom pumps

normal output for infant

1-2 voids daily (3-5 days)
at least 6 voids per day by 4th day

resp rate (baby)

-must count for full minute
-normal 30-60bpm; unlabored, symmetrical chest movement
-pattern/depth irregular

periodic breathing

*NORMAL
pauses in breathing lasting 5-10secs followed by rapid respirations for 10-15secs
more common in preterms

apnea

absence of breathing for 20 secs or longer
-if accompanied w/ cyanosis, pallor, bradycardia, decreased muscle tone\= REPORT IMMEDIATELY
-asses q30mins until stable for 2 hrs after birth

s/s respiratory distress

**TACHYPNEA (\>60; not uncommon in 1st hour or reactivity)
-retractions
-nasal flaring
-cyanosis/acrocyanosis
-grunting
-seesaw (paradoxical) resps
-choanal atresia

suprasternal retractions

intercostal retractions

substernal retractions

cyanosis (central cyanosis/true cyanosis)

includes lips, tongue, mucous membranes & trunk
-assess to ID cyanosis from bruising (apply pressure; blanches\=cyanosis)

Seesaw (paradoxic) respirations

chest falls when abdomen rises & chest rises when abdomen falls
-indicates severe respiratory difficulty
-should rise & fall together

choanal atresia

blockage or narrowing of one or both nasal passages by bone/tissue
-newborns are nose breathers and remain so for 4-6wks except when crying
s/s: assess cyanotic when quiet; pink when crying

normal pulse (newborn)

120-160/min up to 180/min if crying
-murmurs are normal on first day; ALWAYS REPORT!

normal bp (newborn)

65-92/30-60

\>120mmHg higher in upper than lower\= BAD

normal temp (newborn)

97.7-99.5

caput succedanem

edematous area on head from pressure against cervix that may CROSS SUTURE LINES; can occur with vacuum extractor
-resolves quickly & disappears in several days
-assess/document amount of edema & bruising

cephalematoma

soft mass w/ bluish dicoloration r/t bleeding b/t the bone & its covering caused by pressure during birth
-can be on one or both sides of head
-DOES NOT CROSS SUTURE
-develops within 1st 24 hr
-reabsorbs slowly in 2wk-3mos
-risk of jaundice r/t breakdown of RBC

Barlow test

abduct hips & apply gentle pressure down & back w/ thumbs
-feel for femoral head out of acetabulum

ortolani test

abduct thighs & apply gental pressure forward over the greater trochanter
-CLUNKING sensation is DISLOCATED FEMORAL HEAD

spina bifida occulta

failure of vertebrae to close completely
-indentation, especially w/ tuft of hair over it

pilonidal dimple

condition that can occur anywhere along the crease b/t the buttocks, which runs from the bone at the bottom of the spine (sacrum) to the anus

newborn measurements

weight: 5lb 8oz- 8lb 13 oz
(lose 10% in first few days; regains it by 2 wks)
length: 19-21"
head: 32-38cm
chest: 33cm

sensory assessment

measure outer canthus from ear attachment to head

transient strabismus (crossed eyes)

common in newborns r/t weak eye muscle; disappears by 3-4 months
-educate parent that all newborns lack eye muscle control & coordination

bowel obstruction

distention/stretched shiny skin on abdomen could \=

diaphragmatic hernia

sunken appearance of abdomen bc/ intestines are pushed into chest cavity; bowel sound head in chest

umbilical hernia

intestinal muscle fail to close around umbilicus; more common in LBW/males/african-americans; commonly disappears when baby starts walking may require surgery

babinski

reflex tested by stroke lateral sole of the foot from heel to across base of toes

expected: toes flare with dorsiflexion of big toe

abnormal: no response\=bilat CNS deficit; unilat\=local nerve injury

gallant (trunk incurvation)

reflex tested with infant prone, lightly stroke along the side of the vertebral column

expected: entire trunk flexed toward stimulated side

abnormal: no response\=CNS deficit

grasp (palmar & plantars)

reflex tested by press finger against base of infants fingers/toes

expected: fingers curl tightly; toes curl forward

abnormal: weak or absent\=neurologic deficit or muscle injury

moro

reflex tested by letting infant's head drop back approximately 30 degrees

expected: sharp extension & abduction of arms followed by flexion and abduction to embrace position

abnormal: absent\= cns dysfunction, asymmetry, brachial plexus injury, fracture bone
exaggerated: maternal drug use

rooting

reflex tested by touching or stroking side of mouth towards cheek

expected: infant turns head to side touch; difficult ot elicit if infant sleeping or just fed

abnormal: weak or absent\= premature, neuro deficit, depression from maternal drug use

stepping

reflex tested by holding infant feet so they touch solid surface

expected: infant lifts alternate foot as walking

abnormal: asymmetry\=fracture, neuro deficit, maternal drug use

sucking

reflex tested by plcing nipple or gloved finger in mouth, rub against palate

expected: infant begins ot suck; may be weak if just fed

abnormal: weak or abent\= premature, neuro deficit, maternal drug use

swallowing

reflex tested by placing liquid on back of tonge

expected: infant swallows; should be coordinated with sucking

abnormal: coughing, gagging, choking, cyanosis, tracheoesophageal fistula, esophageal atresia, neuro deficit

tonic neck reflex

reflex tested by gently turn head to one side while infant is supine

expected: infant extends extremities on side to which head is turned; with flexion of the opposite

abnormal: prolonged period in position; neuro deficit

erythromycin/tetracycline

prophylactic to prevent ophthalmic neonatorum if mom has gonorrhea or chlamydia

cord care

-assess for bleeding/oozing after birth
-ensure clamp is secure w/no skin caught
-purulent drainage/redness/edema @base\=infection
-cord should be brown/black @ 2-3days; fall off 10-14 days
-keep cord clean with water & dry
-fold diaper away from cord
-clamp may be removed after 24 hrs if end is dry

protecting infant

-making sure infant always goes to right parents
-safeguard from infant abduction
-prevent/recognize early s/s of infection

*ID bands on baby/mom/dad with gender, date/time, delivering MD, mom name, hospital ID \#, barcode

infant abduction

-normally by women familiar w/facility, childbearing age, overweight, previous loss of pregnancy, faked pregnancy to solidify relationship, plans the abduction, waits for right time
-58% of abducted newborns taken form mom's room
*TEACH PARENTS HOW TO RECOGNIZE STAFF

Circumsicision

removal of prepuce (foreskin)
-foreskin can be retracted for cleaning on older child but maybe not until 3-6 y/o
-no medical evidence supports doing/not doing procedure