Maternity Exam Two

postpartum period

begins after the delivery of the placenta and lasts for approximately six weeks.

Involution

refers to the changes the uterus undergo after childbirth to return to their non-pregnant size and condition

Uterine height 6-12 hours after birth

even with umbilicus

Uterine height after 24 hours

1 cm below

Uterine height 3 days after birth

3cm below

uterine height 14 days after birth

non-palpable

Afterpains

intermittent contractions, a source of discomfort for many women. Stronger during breastfeeding, decrease after 48 hours

Lochia Rubra

deep, red mixture of mucus, tissue, and blood that lasts 3-4 days after birth

Lochia Serosa

pink to brown lochia, lasts 3-10 days

Lochia Alba

white to brown, lasts 10-14 days

Factors that facilitate uterine involution

Complete expulsion of placenta, complication free labor, breast feeding, early ambulation

Factors that inhibit involution(increased risk of bleeding)

Prolonged labor and difficult birth, incomplete expulsion of placenta, uterine infection, over distention of uterine muscles, full bladder, anesthesia

Expected vaginal birth blood loss

less than 500ml

expected blood loss C section

less than 1000 mL

why is some blood loss after birth okay?

during pregnancy blood volume can be increased by up to 45%, so some blood loss is expected from the body after childbirth

Postpartum WBC

WBC up to 30,000 mm3 is normal

Coagulation after pregnancy

hypercoagubility state will occur for 2-3 weeks postpartum, increases risk for DVT

Postpartum vital signs

Pulse: 50-70bpm(bradycardia expected, caused by increased blood volume)

Temp: normal to low grade fever(100.5)

Blood pressure:

Orthostatic hypotension postpartum

after brith, a rapid decrease in intraabdominal pressure results in dilation of blood vessels supplying the viscera. Results in rapid decrease in BP

Urinary system adaptations postpartum

GFR and renal plasma flow have been increased throughout pregnancy, normalize by 6 weeks

Adequate output postpartum

>100mL at least for first void

postpartum diuresis

rapid filling of the bladder beginning within 12 hours after birth, continuing for about 1 week. related to large amount of IV fluid given

constipation postpartum

common, caused by decreased bowel motility, fluid loss, iron, and pain medication

Uterine atony symptoms

heavy of excessive bleeding within hours of birth

cervical laceration symptoms

trickling or bright red blood with firm fundus

coagulopathies symptoms

persistant post-partum bleeding without ant identifiable cause

retained placenta symptoms

resumption of bright red bleeding several days after birth

prolactin in lactation

initiates milk production

oxytocin milk production

necessary for milk ejection

return of menstruation in non-lactating women

7-9 weeks after birth

return of menstruation in lactating women

2-18 months after birth

BUBBLEHER

Breasts

Uterus

Bowels

Bladder

Lochia

Episiotomy

Hemorrhoids

Extermities

Emotions

Baby blues

Milk depressive symptoms occurring after birth, normal, especially 5-7 days after birth

how long do baby blues last

peak on postpartum day 4-5, resolve on day 10

Postpartum depression

major depressive disorder, lasting beyond 6 weeks postpartum

Factors that contribute to PPD

hormone fluctuations, prior depressive history, stress, fatigue, difficult pregnancy, high risk/preterm, social isolation

postpartum psychosis

life threatening, symptoms can appear within days of delivery, can develop from PPD

symptoms of PP psychosis

agitation, rapidly shifting mood, disorientation, disorganized behavior, hallucinations, hypomania/mania

Nursing mgmt PP psychosis

identify risk factors, prophylactic interventions, educate about medications and therapy, provide referrals

postpartum hemorrhage

potentially life threatening complication, any amount of bleeding that places mother in hemodynamic jeopardy

What classifies hemorrhage?

Blood loss of:

>500mL vaginally

>1000mL C section

The four T’s of postpartum hemorrhage

The 4 Ts:

• Tone

• Tissue

• Trauma

• Thrombosis

Tone

Uterine Atony, ofter distensin, abnormal labor time(prolonged or rapid), infection

Uterine Atony

Failure of uterus to contract after birth, most common cause of PP hemorrhage

Nursing assessment for bleeding

q15 1-2 hours then q1 for 4 hours

nursing management during hemorrhage

VS q5 until stable, O2 10-15L via mask, palpate fundus, massage prn, pad count, uterotonic drugs

Vital signs in hemorrhage

Thromboembolic conditions

DVT formation due to hypercoaguability postpartum

Postpartum infection

fever >100.4 after 24 hours PP occurring on at least 2 of the first 10 days of birth

Common PP infections

Wound infection, UTI, mastitis

Jaundice in infants

yellowing of skin, sclera, and mucous membranes

Cause of jaundice in infants

results from hyperbillirubemia, excessive bilirubin in blood

Source of bilirubin in infants

hemolysis of RBCs

Physiologic jaundice in infants

occurs at 2-3 days of life, up to 60-80% of newborns will develop due to bilirubin peaking and then declining. normal and safe to occur

Pathologic jaundice

abnormal hemolysis BEFORE 24 hours old, more severe

bilirubin levels pathologic jaundice

increase by more than 5mg/kL/day, levels higher than 17mg/dL

Kerniterus

high levels of bilirubin cause neurologic dysfunction

phototherapy

helps breakdown of bilirubin by liver, cover eyes and genitals, remove eye covers for feeding, reposition every 2 hours

Ectopic Pregnancy

Fertilized ovum implants outside the uterine cavity. Medical emergency, commonly in fallopian tube often due to tubal scarring or infection

Symptoms of ectopic pregnancy

unilateral or bilateral lower abdominal pain, often mistaken as appendicitis

Classic triad ectopic pregnancy

6-8 weeks after missed period, abdominal pain, spotting

treatment ectopic pregnancy

methotrexate, surgery if bleeding is occuring

Gestational thropoplastic disease

aka hydatidiform mole; abnormal growth of placenta, turns into a mole instead of a placenta. Fetal cells may or may not be present, can result in life threatening complications

What can hydatidiform moles cause?

choriocarcinoma

Manifestations hydatidiform mole

high HCg levels, large uterus, browning spotting, early development preeclampsia, absence of FHR

Edcuation hydatidiform mole

test hcg levels for 1 year, avoid pregnancy for 1 year, ultrasounds, X ray, pelvic exams

Placenta previa

bleeding condition during the last 2 trimesters of pregnancy, placenta implants above cervical OS, cause unknown

what does placenta previa cause

hemorrhage, abruption of placenta, emergency C section

treatment placenta previa

“wait and see”, determined by amount of bleeding, location of previa, fetal development, evidence of distress, pelvic rest

Classic presentation placenta previa

painless, bright red vaginal bleeding in second or third trimester

nursing management placenta previa

avoid vaginal exams, assess fetal well being, family support and education

Abrupto placenta

separation of normally located placenta, greater than 20 weeks gestation. Major medical emergency with high mortality rate

Mild abrupto

grade 1: less than 500mL bleeding

moderate abrupto

grade 2: 1000-1500mL

Severe abrupto

grade 3: >1500mL

Concealed vs apparent abruption

Concealed: no obvious bleeding

Apparent: active bleeding from vagina

nursing assessment abrupto placenta

health history: >35 years old, poor nutrition, multiple gestation, cocaine, etoh use, multiparity, increase intrauterine pressure

Classic presentation abruptio placenta

dark red vaginal bleeding and “knife like” abdominal pain

Nursing care abrupto

left sided position, oxygen, IV fluids, fundal assessment, bleeding assessment

DIC: Disseminated intravascular coagulation

bleeding disorder, abnormal reduction of clotting factors, small clots form throughout the body cause inability of clots to form.

S+S DIC

bleeding from gums, tachycardia, oozing IV sites, petechia

Placenta previa vs abruptio placenta

Gestational hypertension

hypertension without proteinuria after 20 weeks gestation

diagnosis gestational HTN

>140/90 x2 at least 6 hours apart

mechanism of gestational hypertension

vasospasm and hypoperfusion during pregnancy

Pathology of preclampsia

• generalized vasospasm and vasoconstriction leading to vascular damage

• Loss of plasma protein into interstitial spaces

  • fluid is drawn into extracellular spaces

  • results in hypovolemia

• hypovolemia results in decreased perfusion to major organs including the uterus

Decreased blood flow to brain preecplampsia

causes headache, visual disturbance, CNS irritability, deep tendon reflexes, convulsions

Decreased blood flow to kidneys preeclampsia

causes edema(general and pulmonary)

decreased blood flow to liver preeclampsia

increased LDH, ALT, AST, epigastric pain

decreased blood flow to placenta preeclampsia

causes fetal hypoxia, acidosis, fetal death

Mild preeclampsia

• 140/90

• 1+ protein

• normal reflexes

• mild edema

• weight gain

Severe preeclampsia

• 160/110

• 3+ protein

• Oliguria

• blurred vision

• pulonary edema

• thrombocytopenia

• cerebral disturbance

• epigastric pain

Ecclampsia

• severe preeclampsia

• 160/110

• Marked proteinuria

• generalized edema

• renal failre

• HELLP

• SEIZURES

HELLP

**H**emolysis(low hct)

**E**levated **L**iver enzyes

**L**ow **P**latelets(

medication to treat preeclampsia

lobetolol

management preeclampsia

bed rest, nonstress testing, daily BP check, protein checks

Lobetolol dosage

10-20mg IV, 20-80mg every 20-30 minutes to a max dose of 300mg OR constant infusion 1-2mg/min IV

contraindication labetolol

asthma, heart disease, CHF

adverse effects labetolol

gastric pain, flatulance, constipation, dizziness, vertigo, fatigue

Risk gestational diabetes

previous infant with congenital abnormality, history of diabtes, family history, >35 years, previous infant >8lbs 13 oz(4000g), maternal obesity