bull determine which quadrant presenting part (occiput) is pointing towards
Passengerbull Occiput Anterior (LOA amp ROA) most
common positions amp easiest for birth
bull Occiput Posterior (LOP amp ROP) bull can prolong both 1st amp 2nd stage of laborbull back pain during UCs (back labor)bull Instruct partner in sacral pressure during UCrsquosbull Try ldquoall foursrdquo knee-chest or alternate side-
lying positions to encourage baby to rotate to anterior position
Powersbull Contractions supplied by fundus of uterus
bull Involuntary become stronger as labor progresses
bull Abdominal muscles ldquopushingrdquo by mom (2nd stage)
Psychebull Psychological state amp feelings of mom
bull Coping skillsbull Anxiety fear stressbull Labor support
Onset of laborbull Usually begins between 38 amp 42 weeksbull Mechanism is unknownbull Upper uterus contracts downward pushing
presenting part on cervix causing effacement and dilatation
bull Premonitory signs of laborbull Lightening Braxton-Hicks contractions (false
labor)bull cervical changes (ripening) bull bloody show (mucous plug) bull rupture of membranes (ROM) bull sudden burst of energy
False vs True Labor Contractions
False Labor
bull Benign and irregular contractions
bull Felt first abdominally and remain confined to the abdomen and groin
bull Often disappear with ambulation and sleep
bull Do not increase in duration frequency or intensity
True Laborbull Begin irregularly but
become regular and predictable
bull Felt first in lower back and sweep around to the abdomen in a wave
bull Continue no matter what the womenrsquos level of activity
bull Increase in duration frequency and intensity
False vs True Labor Cervix
False Laborbull No significant
change in dilation or effacement
bull No significant bloody show
bull Fetus- presenting part is not engaged in pelvis
True Laborbull Progressive
change in dilation and effacement
bull Bloody show
bull Presenting part engages in pelvis
Critical Thinkingbull A primigravida client has just arrived in the birthing
unit What steps would be most important for the nurse to perform to gain an understanding of the physical status of the client and her fetus
A Check for ruptured membranes and apply a fetal scalp electrode
B Auscultate the fetal heart rate between and during contractions
C Palpate contractions and resting uterine tone
D Perform a vaginal exam for cervical dilation and perform Leopolds maneuvers
E Determine gestational age of fetus
Stages of Labor First Stage
bull 0 to 10 cm dilatation--opening of cervix)bull Latent slowest part of the process--slow
dilation mild contractionsbull from onset of regular UCs to rapid
dilatation (about 3-4 cms)bull Active labor ldquopicks up steamrdquo--period of
more rapid dilationbull from 4 cm to full dilatation stronger UCsbull Transition 7-10 cm--intense NV shaking
EffacementThinning of cervix(in )
StationDescent of fetal head(in cm)
Descent offetal head
Station
Floating
Engaged
At outletcrowning
Dilatation amp Effacement
>
Care of Laboring PatientEarly Labor
bull Initial physical assessment amp history
bull Admission--rapportbull Fetal amp UC
monitoringbull Vaginal exams q 2
hoursbull Vital signsbull Temperature q 4
hours-intact or q 2 hours ROM
bull Educate regarding labor
bull Encourage comfort position changes bladder emptying
bull Assess pain pain tolerance preferred type of labordelivery
bull Reassure regarding what is normal reduce anxiety
Couple excited talkative pain is manageable
Care of Laboring Patient Active Labor
bull Transition (7-10 cm) Yikes ldquoout of controlrdquo shaking nauseavomiting sweating pain is intensebull Prepare for delivery
bull Second stage (Pushing)bull Educateinstruct regarding pushingbull Assess urge to push and fetal descentbull Encouragemotivate patient assess fatiguebull Monitor fetalmaternal response to pushing
bulge crowningbull Signs of imminent birth perineal bulging
Couple quieter discouraged pain increasing
Stages of LaborSecond Stage
bull Pushing amp descent of baby (STATION)bull Full dilatation (10 cm) to birth
bull Important NOT to push until full dilationbull Assessment Urge to push Rectal
pressurebull Push only with UCrsquosbull Crowning babyrsquos head is visible at the
Mechanisms of labor A B Descent C Internal rotation D Extension E External rotation
Head Rotation during Descent
>
Crowning
In the hospital
Alternative settings
Crowning
Stages of Labor Third Stage
bull Placental stage from birth to delivery of placenta
bull Placental separation from uterine wall (rise of fundus sudden gush of blood lengthening of umbilical cord)
bull Entire lining of uterus shedbull Expulsion of placenta
bull Normal blood loss 300-500 mLbull If placenta does not deliver spontaneously can
be delivered manuallybull Pitocin infusion started immediately post
delivery of placenta
Critical Thinkingbull
A client is admitted to the labor unit with contractions 2 to 3 minutes apart and lasting 60 to 90 seconds The client is apprehensive and vomiting This nurse understands this information to indicate that the client is most likely in what phase of labor
bull A) Active bull B) Transition bull C) Latent bull D) Second
bull Stop pitocinbull Reposition to left lateral Trendelenberg if neededbull Oxygen via mask at 8-10 Lminbull Increase IV fluidsbull SQ terbutaline (025 mg) if uterus not relaxingbull Vaginal exam for possible cause prolapse fetal
descent rupture abruptionbull Amnioinfusion for variable decelsbull Notify MDmidwife
Which strip shows signs thatImmediate intervention is needed Why What would you do
A
B
Experiences of Pain
bull Etiology bull Physiologybull Perception
bull Factors influencingAnxiety Psychological factorsExpectations Cultural factors
Support Fetal position
Comfort and Pain Relief
bull Support from doula or coachbull Alternative therapies
bullRelaxationmassagebull Focusing and imagerybullBreathingbullHerbal preparationsaromatherapybullHypnosis
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Induction
bull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessment
bull Bishop Score- rating that determines if the cervix is ready for induction--Pg 765
bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole
-Inadequate uterine relaxation between contractions
lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveries
bull Forcepsbull Indications unable to push arrested descent need a
quick delivery breechbull Associated with maternalfetal birth trauma rectal
sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina
Cervix returns to firm nongravid consistency by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum
Assessment turn pt to side in Simrsquos position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy
Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments
Constipation Give stool softeners as ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis
Superficial leg vein diseasendash Ss tenderness in portion of vein local heat amp
redness normal temperature or low-grade feverndash Tx local heat elevate limb bed rest analgesia
elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation
Engorgement day 3 or 4ndash If breastfeeding
Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions
Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
bull determine which quadrant presenting part (occiput) is pointing towards
Passengerbull Occiput Anterior (LOA amp ROA) most
common positions amp easiest for birth
bull Occiput Posterior (LOP amp ROP) bull can prolong both 1st amp 2nd stage of laborbull back pain during UCs (back labor)bull Instruct partner in sacral pressure during UCrsquosbull Try ldquoall foursrdquo knee-chest or alternate side-
lying positions to encourage baby to rotate to anterior position
Powersbull Contractions supplied by fundus of uterus
bull Involuntary become stronger as labor progresses
bull Abdominal muscles ldquopushingrdquo by mom (2nd stage)
Psychebull Psychological state amp feelings of mom
bull Coping skillsbull Anxiety fear stressbull Labor support
Onset of laborbull Usually begins between 38 amp 42 weeksbull Mechanism is unknownbull Upper uterus contracts downward pushing
presenting part on cervix causing effacement and dilatation
bull Premonitory signs of laborbull Lightening Braxton-Hicks contractions (false
labor)bull cervical changes (ripening) bull bloody show (mucous plug) bull rupture of membranes (ROM) bull sudden burst of energy
False vs True Labor Contractions
False Labor
bull Benign and irregular contractions
bull Felt first abdominally and remain confined to the abdomen and groin
bull Often disappear with ambulation and sleep
bull Do not increase in duration frequency or intensity
True Laborbull Begin irregularly but
become regular and predictable
bull Felt first in lower back and sweep around to the abdomen in a wave
bull Continue no matter what the womenrsquos level of activity
bull Increase in duration frequency and intensity
False vs True Labor Cervix
False Laborbull No significant
change in dilation or effacement
bull No significant bloody show
bull Fetus- presenting part is not engaged in pelvis
True Laborbull Progressive
change in dilation and effacement
bull Bloody show
bull Presenting part engages in pelvis
Critical Thinkingbull A primigravida client has just arrived in the birthing
unit What steps would be most important for the nurse to perform to gain an understanding of the physical status of the client and her fetus
A Check for ruptured membranes and apply a fetal scalp electrode
B Auscultate the fetal heart rate between and during contractions
C Palpate contractions and resting uterine tone
D Perform a vaginal exam for cervical dilation and perform Leopolds maneuvers
E Determine gestational age of fetus
Stages of Labor First Stage
bull 0 to 10 cm dilatation--opening of cervix)bull Latent slowest part of the process--slow
dilation mild contractionsbull from onset of regular UCs to rapid
dilatation (about 3-4 cms)bull Active labor ldquopicks up steamrdquo--period of
more rapid dilationbull from 4 cm to full dilatation stronger UCsbull Transition 7-10 cm--intense NV shaking
EffacementThinning of cervix(in )
StationDescent of fetal head(in cm)
Descent offetal head
Station
Floating
Engaged
At outletcrowning
Dilatation amp Effacement
>
Care of Laboring PatientEarly Labor
bull Initial physical assessment amp history
bull Admission--rapportbull Fetal amp UC
monitoringbull Vaginal exams q 2
hoursbull Vital signsbull Temperature q 4
hours-intact or q 2 hours ROM
bull Educate regarding labor
bull Encourage comfort position changes bladder emptying
bull Assess pain pain tolerance preferred type of labordelivery
bull Reassure regarding what is normal reduce anxiety
Couple excited talkative pain is manageable
Care of Laboring Patient Active Labor
bull Transition (7-10 cm) Yikes ldquoout of controlrdquo shaking nauseavomiting sweating pain is intensebull Prepare for delivery
bull Second stage (Pushing)bull Educateinstruct regarding pushingbull Assess urge to push and fetal descentbull Encouragemotivate patient assess fatiguebull Monitor fetalmaternal response to pushing
bulge crowningbull Signs of imminent birth perineal bulging
Couple quieter discouraged pain increasing
Stages of LaborSecond Stage
bull Pushing amp descent of baby (STATION)bull Full dilatation (10 cm) to birth
bull Important NOT to push until full dilationbull Assessment Urge to push Rectal
pressurebull Push only with UCrsquosbull Crowning babyrsquos head is visible at the
Mechanisms of labor A B Descent C Internal rotation D Extension E External rotation
Head Rotation during Descent
>
Crowning
In the hospital
Alternative settings
Crowning
Stages of Labor Third Stage
bull Placental stage from birth to delivery of placenta
bull Placental separation from uterine wall (rise of fundus sudden gush of blood lengthening of umbilical cord)
bull Entire lining of uterus shedbull Expulsion of placenta
bull Normal blood loss 300-500 mLbull If placenta does not deliver spontaneously can
be delivered manuallybull Pitocin infusion started immediately post
delivery of placenta
Critical Thinkingbull
A client is admitted to the labor unit with contractions 2 to 3 minutes apart and lasting 60 to 90 seconds The client is apprehensive and vomiting This nurse understands this information to indicate that the client is most likely in what phase of labor
bull A) Active bull B) Transition bull C) Latent bull D) Second
bull Stop pitocinbull Reposition to left lateral Trendelenberg if neededbull Oxygen via mask at 8-10 Lminbull Increase IV fluidsbull SQ terbutaline (025 mg) if uterus not relaxingbull Vaginal exam for possible cause prolapse fetal
descent rupture abruptionbull Amnioinfusion for variable decelsbull Notify MDmidwife
Which strip shows signs thatImmediate intervention is needed Why What would you do
A
B
Experiences of Pain
bull Etiology bull Physiologybull Perception
bull Factors influencingAnxiety Psychological factorsExpectations Cultural factors
Support Fetal position
Comfort and Pain Relief
bull Support from doula or coachbull Alternative therapies
bullRelaxationmassagebull Focusing and imagerybullBreathingbullHerbal preparationsaromatherapybullHypnosis
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Induction
bull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessment
bull Bishop Score- rating that determines if the cervix is ready for induction--Pg 765
bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole
-Inadequate uterine relaxation between contractions
lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveries
bull Forcepsbull Indications unable to push arrested descent need a
quick delivery breechbull Associated with maternalfetal birth trauma rectal
sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina
Cervix returns to firm nongravid consistency by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum
Assessment turn pt to side in Simrsquos position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy
Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments
Constipation Give stool softeners as ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis
Superficial leg vein diseasendash Ss tenderness in portion of vein local heat amp
redness normal temperature or low-grade feverndash Tx local heat elevate limb bed rest analgesia
elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation
Engorgement day 3 or 4ndash If breastfeeding
Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions
Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
bull determine which quadrant presenting part (occiput) is pointing towards
Passengerbull Occiput Anterior (LOA amp ROA) most
common positions amp easiest for birth
bull Occiput Posterior (LOP amp ROP) bull can prolong both 1st amp 2nd stage of laborbull back pain during UCs (back labor)bull Instruct partner in sacral pressure during UCrsquosbull Try ldquoall foursrdquo knee-chest or alternate side-
lying positions to encourage baby to rotate to anterior position
Powersbull Contractions supplied by fundus of uterus
bull Involuntary become stronger as labor progresses
bull Abdominal muscles ldquopushingrdquo by mom (2nd stage)
Psychebull Psychological state amp feelings of mom
bull Coping skillsbull Anxiety fear stressbull Labor support
Onset of laborbull Usually begins between 38 amp 42 weeksbull Mechanism is unknownbull Upper uterus contracts downward pushing
presenting part on cervix causing effacement and dilatation
bull Premonitory signs of laborbull Lightening Braxton-Hicks contractions (false
labor)bull cervical changes (ripening) bull bloody show (mucous plug) bull rupture of membranes (ROM) bull sudden burst of energy
False vs True Labor Contractions
False Labor
bull Benign and irregular contractions
bull Felt first abdominally and remain confined to the abdomen and groin
bull Often disappear with ambulation and sleep
bull Do not increase in duration frequency or intensity
True Laborbull Begin irregularly but
become regular and predictable
bull Felt first in lower back and sweep around to the abdomen in a wave
bull Continue no matter what the womenrsquos level of activity
bull Increase in duration frequency and intensity
False vs True Labor Cervix
False Laborbull No significant
change in dilation or effacement
bull No significant bloody show
bull Fetus- presenting part is not engaged in pelvis
True Laborbull Progressive
change in dilation and effacement
bull Bloody show
bull Presenting part engages in pelvis
Critical Thinkingbull A primigravida client has just arrived in the birthing
unit What steps would be most important for the nurse to perform to gain an understanding of the physical status of the client and her fetus
A Check for ruptured membranes and apply a fetal scalp electrode
B Auscultate the fetal heart rate between and during contractions
C Palpate contractions and resting uterine tone
D Perform a vaginal exam for cervical dilation and perform Leopolds maneuvers
E Determine gestational age of fetus
Stages of Labor First Stage
bull 0 to 10 cm dilatation--opening of cervix)bull Latent slowest part of the process--slow
dilation mild contractionsbull from onset of regular UCs to rapid
dilatation (about 3-4 cms)bull Active labor ldquopicks up steamrdquo--period of
more rapid dilationbull from 4 cm to full dilatation stronger UCsbull Transition 7-10 cm--intense NV shaking
EffacementThinning of cervix(in )
StationDescent of fetal head(in cm)
Descent offetal head
Station
Floating
Engaged
At outletcrowning
Dilatation amp Effacement
>
Care of Laboring PatientEarly Labor
bull Initial physical assessment amp history
bull Admission--rapportbull Fetal amp UC
monitoringbull Vaginal exams q 2
hoursbull Vital signsbull Temperature q 4
hours-intact or q 2 hours ROM
bull Educate regarding labor
bull Encourage comfort position changes bladder emptying
bull Assess pain pain tolerance preferred type of labordelivery
bull Reassure regarding what is normal reduce anxiety
Couple excited talkative pain is manageable
Care of Laboring Patient Active Labor
bull Transition (7-10 cm) Yikes ldquoout of controlrdquo shaking nauseavomiting sweating pain is intensebull Prepare for delivery
bull Second stage (Pushing)bull Educateinstruct regarding pushingbull Assess urge to push and fetal descentbull Encouragemotivate patient assess fatiguebull Monitor fetalmaternal response to pushing
bulge crowningbull Signs of imminent birth perineal bulging
Couple quieter discouraged pain increasing
Stages of LaborSecond Stage
bull Pushing amp descent of baby (STATION)bull Full dilatation (10 cm) to birth
bull Important NOT to push until full dilationbull Assessment Urge to push Rectal
pressurebull Push only with UCrsquosbull Crowning babyrsquos head is visible at the
Mechanisms of labor A B Descent C Internal rotation D Extension E External rotation
Head Rotation during Descent
>
Crowning
In the hospital
Alternative settings
Crowning
Stages of Labor Third Stage
bull Placental stage from birth to delivery of placenta
bull Placental separation from uterine wall (rise of fundus sudden gush of blood lengthening of umbilical cord)
bull Entire lining of uterus shedbull Expulsion of placenta
bull Normal blood loss 300-500 mLbull If placenta does not deliver spontaneously can
be delivered manuallybull Pitocin infusion started immediately post
delivery of placenta
Critical Thinkingbull
A client is admitted to the labor unit with contractions 2 to 3 minutes apart and lasting 60 to 90 seconds The client is apprehensive and vomiting This nurse understands this information to indicate that the client is most likely in what phase of labor
bull A) Active bull B) Transition bull C) Latent bull D) Second
bull Stop pitocinbull Reposition to left lateral Trendelenberg if neededbull Oxygen via mask at 8-10 Lminbull Increase IV fluidsbull SQ terbutaline (025 mg) if uterus not relaxingbull Vaginal exam for possible cause prolapse fetal
descent rupture abruptionbull Amnioinfusion for variable decelsbull Notify MDmidwife
Which strip shows signs thatImmediate intervention is needed Why What would you do
A
B
Experiences of Pain
bull Etiology bull Physiologybull Perception
bull Factors influencingAnxiety Psychological factorsExpectations Cultural factors
Support Fetal position
Comfort and Pain Relief
bull Support from doula or coachbull Alternative therapies
bullRelaxationmassagebull Focusing and imagerybullBreathingbullHerbal preparationsaromatherapybullHypnosis
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Induction
bull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessment
bull Bishop Score- rating that determines if the cervix is ready for induction--Pg 765
bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole
-Inadequate uterine relaxation between contractions
lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveries
bull Forcepsbull Indications unable to push arrested descent need a
quick delivery breechbull Associated with maternalfetal birth trauma rectal
sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina
Cervix returns to firm nongravid consistency by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum
Assessment turn pt to side in Simrsquos position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy
Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments
Constipation Give stool softeners as ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis
Superficial leg vein diseasendash Ss tenderness in portion of vein local heat amp
redness normal temperature or low-grade feverndash Tx local heat elevate limb bed rest analgesia
elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation
Engorgement day 3 or 4ndash If breastfeeding
Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions
Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
bull determine which quadrant presenting part (occiput) is pointing towards
Passengerbull Occiput Anterior (LOA amp ROA) most
common positions amp easiest for birth
bull Occiput Posterior (LOP amp ROP) bull can prolong both 1st amp 2nd stage of laborbull back pain during UCs (back labor)bull Instruct partner in sacral pressure during UCrsquosbull Try ldquoall foursrdquo knee-chest or alternate side-
lying positions to encourage baby to rotate to anterior position
Powersbull Contractions supplied by fundus of uterus
bull Involuntary become stronger as labor progresses
bull Abdominal muscles ldquopushingrdquo by mom (2nd stage)
Psychebull Psychological state amp feelings of mom
bull Coping skillsbull Anxiety fear stressbull Labor support
Onset of laborbull Usually begins between 38 amp 42 weeksbull Mechanism is unknownbull Upper uterus contracts downward pushing
presenting part on cervix causing effacement and dilatation
bull Premonitory signs of laborbull Lightening Braxton-Hicks contractions (false
labor)bull cervical changes (ripening) bull bloody show (mucous plug) bull rupture of membranes (ROM) bull sudden burst of energy
False vs True Labor Contractions
False Labor
bull Benign and irregular contractions
bull Felt first abdominally and remain confined to the abdomen and groin
bull Often disappear with ambulation and sleep
bull Do not increase in duration frequency or intensity
True Laborbull Begin irregularly but
become regular and predictable
bull Felt first in lower back and sweep around to the abdomen in a wave
bull Continue no matter what the womenrsquos level of activity
bull Increase in duration frequency and intensity
False vs True Labor Cervix
False Laborbull No significant
change in dilation or effacement
bull No significant bloody show
bull Fetus- presenting part is not engaged in pelvis
True Laborbull Progressive
change in dilation and effacement
bull Bloody show
bull Presenting part engages in pelvis
Critical Thinkingbull A primigravida client has just arrived in the birthing
unit What steps would be most important for the nurse to perform to gain an understanding of the physical status of the client and her fetus
A Check for ruptured membranes and apply a fetal scalp electrode
B Auscultate the fetal heart rate between and during contractions
C Palpate contractions and resting uterine tone
D Perform a vaginal exam for cervical dilation and perform Leopolds maneuvers
E Determine gestational age of fetus
Stages of Labor First Stage
bull 0 to 10 cm dilatation--opening of cervix)bull Latent slowest part of the process--slow
dilation mild contractionsbull from onset of regular UCs to rapid
dilatation (about 3-4 cms)bull Active labor ldquopicks up steamrdquo--period of
more rapid dilationbull from 4 cm to full dilatation stronger UCsbull Transition 7-10 cm--intense NV shaking
EffacementThinning of cervix(in )
StationDescent of fetal head(in cm)
Descent offetal head
Station
Floating
Engaged
At outletcrowning
Dilatation amp Effacement
>
Care of Laboring PatientEarly Labor
bull Initial physical assessment amp history
bull Admission--rapportbull Fetal amp UC
monitoringbull Vaginal exams q 2
hoursbull Vital signsbull Temperature q 4
hours-intact or q 2 hours ROM
bull Educate regarding labor
bull Encourage comfort position changes bladder emptying
bull Assess pain pain tolerance preferred type of labordelivery
bull Reassure regarding what is normal reduce anxiety
Couple excited talkative pain is manageable
Care of Laboring Patient Active Labor
bull Transition (7-10 cm) Yikes ldquoout of controlrdquo shaking nauseavomiting sweating pain is intensebull Prepare for delivery
bull Second stage (Pushing)bull Educateinstruct regarding pushingbull Assess urge to push and fetal descentbull Encouragemotivate patient assess fatiguebull Monitor fetalmaternal response to pushing
bulge crowningbull Signs of imminent birth perineal bulging
Couple quieter discouraged pain increasing
Stages of LaborSecond Stage
bull Pushing amp descent of baby (STATION)bull Full dilatation (10 cm) to birth
bull Important NOT to push until full dilationbull Assessment Urge to push Rectal
pressurebull Push only with UCrsquosbull Crowning babyrsquos head is visible at the
Mechanisms of labor A B Descent C Internal rotation D Extension E External rotation
Head Rotation during Descent
>
Crowning
In the hospital
Alternative settings
Crowning
Stages of Labor Third Stage
bull Placental stage from birth to delivery of placenta
bull Placental separation from uterine wall (rise of fundus sudden gush of blood lengthening of umbilical cord)
bull Entire lining of uterus shedbull Expulsion of placenta
bull Normal blood loss 300-500 mLbull If placenta does not deliver spontaneously can
be delivered manuallybull Pitocin infusion started immediately post
delivery of placenta
Critical Thinkingbull
A client is admitted to the labor unit with contractions 2 to 3 minutes apart and lasting 60 to 90 seconds The client is apprehensive and vomiting This nurse understands this information to indicate that the client is most likely in what phase of labor
bull A) Active bull B) Transition bull C) Latent bull D) Second
bull Stop pitocinbull Reposition to left lateral Trendelenberg if neededbull Oxygen via mask at 8-10 Lminbull Increase IV fluidsbull SQ terbutaline (025 mg) if uterus not relaxingbull Vaginal exam for possible cause prolapse fetal
descent rupture abruptionbull Amnioinfusion for variable decelsbull Notify MDmidwife
Which strip shows signs thatImmediate intervention is needed Why What would you do
A
B
Experiences of Pain
bull Etiology bull Physiologybull Perception
bull Factors influencingAnxiety Psychological factorsExpectations Cultural factors
Support Fetal position
Comfort and Pain Relief
bull Support from doula or coachbull Alternative therapies
bullRelaxationmassagebull Focusing and imagerybullBreathingbullHerbal preparationsaromatherapybullHypnosis
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Induction
bull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessment
bull Bishop Score- rating that determines if the cervix is ready for induction--Pg 765
bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole
-Inadequate uterine relaxation between contractions
lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveries
bull Forcepsbull Indications unable to push arrested descent need a
quick delivery breechbull Associated with maternalfetal birth trauma rectal
sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina
Cervix returns to firm nongravid consistency by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum
Assessment turn pt to side in Simrsquos position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy
Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments
Constipation Give stool softeners as ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis
Superficial leg vein diseasendash Ss tenderness in portion of vein local heat amp
redness normal temperature or low-grade feverndash Tx local heat elevate limb bed rest analgesia
elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation
Engorgement day 3 or 4ndash If breastfeeding
Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions
Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
bull determine which quadrant presenting part (occiput) is pointing towards
Passengerbull Occiput Anterior (LOA amp ROA) most
common positions amp easiest for birth
bull Occiput Posterior (LOP amp ROP) bull can prolong both 1st amp 2nd stage of laborbull back pain during UCs (back labor)bull Instruct partner in sacral pressure during UCrsquosbull Try ldquoall foursrdquo knee-chest or alternate side-
lying positions to encourage baby to rotate to anterior position
Powersbull Contractions supplied by fundus of uterus
bull Involuntary become stronger as labor progresses
bull Abdominal muscles ldquopushingrdquo by mom (2nd stage)
Psychebull Psychological state amp feelings of mom
bull Coping skillsbull Anxiety fear stressbull Labor support
Onset of laborbull Usually begins between 38 amp 42 weeksbull Mechanism is unknownbull Upper uterus contracts downward pushing
presenting part on cervix causing effacement and dilatation
bull Premonitory signs of laborbull Lightening Braxton-Hicks contractions (false
labor)bull cervical changes (ripening) bull bloody show (mucous plug) bull rupture of membranes (ROM) bull sudden burst of energy
False vs True Labor Contractions
False Labor
bull Benign and irregular contractions
bull Felt first abdominally and remain confined to the abdomen and groin
bull Often disappear with ambulation and sleep
bull Do not increase in duration frequency or intensity
True Laborbull Begin irregularly but
become regular and predictable
bull Felt first in lower back and sweep around to the abdomen in a wave
bull Continue no matter what the womenrsquos level of activity
bull Increase in duration frequency and intensity
False vs True Labor Cervix
False Laborbull No significant
change in dilation or effacement
bull No significant bloody show
bull Fetus- presenting part is not engaged in pelvis
True Laborbull Progressive
change in dilation and effacement
bull Bloody show
bull Presenting part engages in pelvis
Critical Thinkingbull A primigravida client has just arrived in the birthing
unit What steps would be most important for the nurse to perform to gain an understanding of the physical status of the client and her fetus
A Check for ruptured membranes and apply a fetal scalp electrode
B Auscultate the fetal heart rate between and during contractions
C Palpate contractions and resting uterine tone
D Perform a vaginal exam for cervical dilation and perform Leopolds maneuvers
E Determine gestational age of fetus
Stages of Labor First Stage
bull 0 to 10 cm dilatation--opening of cervix)bull Latent slowest part of the process--slow
dilation mild contractionsbull from onset of regular UCs to rapid
dilatation (about 3-4 cms)bull Active labor ldquopicks up steamrdquo--period of
more rapid dilationbull from 4 cm to full dilatation stronger UCsbull Transition 7-10 cm--intense NV shaking
EffacementThinning of cervix(in )
StationDescent of fetal head(in cm)
Descent offetal head
Station
Floating
Engaged
At outletcrowning
Dilatation amp Effacement
>
Care of Laboring PatientEarly Labor
bull Initial physical assessment amp history
bull Admission--rapportbull Fetal amp UC
monitoringbull Vaginal exams q 2
hoursbull Vital signsbull Temperature q 4
hours-intact or q 2 hours ROM
bull Educate regarding labor
bull Encourage comfort position changes bladder emptying
bull Assess pain pain tolerance preferred type of labordelivery
bull Reassure regarding what is normal reduce anxiety
Couple excited talkative pain is manageable
Care of Laboring Patient Active Labor
bull Transition (7-10 cm) Yikes ldquoout of controlrdquo shaking nauseavomiting sweating pain is intensebull Prepare for delivery
bull Second stage (Pushing)bull Educateinstruct regarding pushingbull Assess urge to push and fetal descentbull Encouragemotivate patient assess fatiguebull Monitor fetalmaternal response to pushing
bulge crowningbull Signs of imminent birth perineal bulging
Couple quieter discouraged pain increasing
Stages of LaborSecond Stage
bull Pushing amp descent of baby (STATION)bull Full dilatation (10 cm) to birth
bull Important NOT to push until full dilationbull Assessment Urge to push Rectal
pressurebull Push only with UCrsquosbull Crowning babyrsquos head is visible at the
Mechanisms of labor A B Descent C Internal rotation D Extension E External rotation
Head Rotation during Descent
>
Crowning
In the hospital
Alternative settings
Crowning
Stages of Labor Third Stage
bull Placental stage from birth to delivery of placenta
bull Placental separation from uterine wall (rise of fundus sudden gush of blood lengthening of umbilical cord)
bull Entire lining of uterus shedbull Expulsion of placenta
bull Normal blood loss 300-500 mLbull If placenta does not deliver spontaneously can
be delivered manuallybull Pitocin infusion started immediately post
delivery of placenta
Critical Thinkingbull
A client is admitted to the labor unit with contractions 2 to 3 minutes apart and lasting 60 to 90 seconds The client is apprehensive and vomiting This nurse understands this information to indicate that the client is most likely in what phase of labor
bull A) Active bull B) Transition bull C) Latent bull D) Second
bull Stop pitocinbull Reposition to left lateral Trendelenberg if neededbull Oxygen via mask at 8-10 Lminbull Increase IV fluidsbull SQ terbutaline (025 mg) if uterus not relaxingbull Vaginal exam for possible cause prolapse fetal
descent rupture abruptionbull Amnioinfusion for variable decelsbull Notify MDmidwife
Which strip shows signs thatImmediate intervention is needed Why What would you do
A
B
Experiences of Pain
bull Etiology bull Physiologybull Perception
bull Factors influencingAnxiety Psychological factorsExpectations Cultural factors
Support Fetal position
Comfort and Pain Relief
bull Support from doula or coachbull Alternative therapies
bullRelaxationmassagebull Focusing and imagerybullBreathingbullHerbal preparationsaromatherapybullHypnosis
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Induction
bull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessment
bull Bishop Score- rating that determines if the cervix is ready for induction--Pg 765
bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole
-Inadequate uterine relaxation between contractions
lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveries
bull Forcepsbull Indications unable to push arrested descent need a
quick delivery breechbull Associated with maternalfetal birth trauma rectal
sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina
Cervix returns to firm nongravid consistency by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum
Assessment turn pt to side in Simrsquos position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy
Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments
Constipation Give stool softeners as ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis
Superficial leg vein diseasendash Ss tenderness in portion of vein local heat amp
redness normal temperature or low-grade feverndash Tx local heat elevate limb bed rest analgesia
elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation
Engorgement day 3 or 4ndash If breastfeeding
Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions
Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Chapter 22--Processes amp Stages of Labor and Birth
Critical Factors In Labor
Passenger
Slide 4
Slide 5
Fetal Lie and Presentation
Slide 7
Passenger (2)
Powers
Onset of labor
False vs True Labor Contractions
False vs True Labor Cervix
Critical Thinking
Stages of Labor First Stage
Slide 15
Slide 16
Slide 17
Dilatation amp Effacement
Care of Laboring Patient Early Labor
Care of Laboring Patient Active Labor
Stages of Labor Second Stage
Slide 22
Head Rotation during Descent
Slide 24
Stages of Labor Third Stage
Critical Thinking (2)
Chapter 23 Intrapartal Nursing Assessment
Initial Intrapartum Assessment Pages 608-612
Intrauterine Fetal Resuscitation
Slide 30
Experiences of Pain
Comfort and Pain Relief
Comfort and Pain Relief (2)
Systemic Analgesia Table 25-3 pg 690
Regional Anesthesia
Slide 36
Medication for Pain Relief Birth
Local anesthesia for Episiotomy
Childbirth at Risk (Ch 26)
Critical Thinking (3)
Precipitous Labor amp Birth
Postterm Pregnancy
Malpresentations
Malpresentations (cont)
External Version
MacrosomiaShoulder Dystocia
Slide 47
McRoberts Maneuvers Video
Multiple Gestation
Multiple Gestation (cont)
Abruptio Placentae
Slide 52
Abruptio Placentae (cont)
Placenta Previa
Slide 55
Prolapsed Cord
Prolapsed Cord (2)
Birth Related Procedures Chapter 27
Methods of Induction
Indications for induction of labor
Contraindications to Induction
Cervical Ripening Assessment
Oxytocin Induction pg 767
When to Discontinue Oxytocin
Operative Assisted Deliveries
Slide 66
Cesarean Birth Indications for
Cesarean Birth (cont)
Slide 69
Cesarean Birth
Post-Op Care
Critical Thinking (4)
POSTPARTUM CARE
Slide 74
Postpartum Psychological Adaptations Reva Rubin
Maternal Responses to Newborn Reva Rubin
Blues vs Dpression
Endocrine Adaptations
Physiological Adaptations
Slide 80
Fundal Assessment
Slide 82
Lochia
Lochia Assessment
Lochia Assessment (2)
Cervix amp Vagina
Perineum
Episiotomy
Other Assessments
Thrombophlebitis
Urinary Retention
Vital Signs
Breast Assessment
Lactation
Discharge Instructions
Postpartum Complications
Hemorrhage
Hemorrhage (cont)
Hematomas
Postpartum Infection
Postpartum Infection (2)
Endometritis
Postpartum Infection (3)
Slide 104
Slide 105
Slide 107
Slide 108
Slide 109
Slide 110
Breastfeeding
Fetal position bull momrsquos
pelvis is divided into 4 quadrants RA RP LA LP
bull determine which quadrant presenting part (occiput) is pointing towards
Passengerbull Occiput Anterior (LOA amp ROA) most
common positions amp easiest for birth
bull Occiput Posterior (LOP amp ROP) bull can prolong both 1st amp 2nd stage of laborbull back pain during UCs (back labor)bull Instruct partner in sacral pressure during UCrsquosbull Try ldquoall foursrdquo knee-chest or alternate side-
lying positions to encourage baby to rotate to anterior position
Powersbull Contractions supplied by fundus of uterus
bull Involuntary become stronger as labor progresses
bull Abdominal muscles ldquopushingrdquo by mom (2nd stage)
Psychebull Psychological state amp feelings of mom
bull Coping skillsbull Anxiety fear stressbull Labor support
Onset of laborbull Usually begins between 38 amp 42 weeksbull Mechanism is unknownbull Upper uterus contracts downward pushing
presenting part on cervix causing effacement and dilatation
bull Premonitory signs of laborbull Lightening Braxton-Hicks contractions (false
labor)bull cervical changes (ripening) bull bloody show (mucous plug) bull rupture of membranes (ROM) bull sudden burst of energy
False vs True Labor Contractions
False Labor
bull Benign and irregular contractions
bull Felt first abdominally and remain confined to the abdomen and groin
bull Often disappear with ambulation and sleep
bull Do not increase in duration frequency or intensity
True Laborbull Begin irregularly but
become regular and predictable
bull Felt first in lower back and sweep around to the abdomen in a wave
bull Continue no matter what the womenrsquos level of activity
bull Increase in duration frequency and intensity
False vs True Labor Cervix
False Laborbull No significant
change in dilation or effacement
bull No significant bloody show
bull Fetus- presenting part is not engaged in pelvis
True Laborbull Progressive
change in dilation and effacement
bull Bloody show
bull Presenting part engages in pelvis
Critical Thinkingbull A primigravida client has just arrived in the birthing
unit What steps would be most important for the nurse to perform to gain an understanding of the physical status of the client and her fetus
A Check for ruptured membranes and apply a fetal scalp electrode
B Auscultate the fetal heart rate between and during contractions
C Palpate contractions and resting uterine tone
D Perform a vaginal exam for cervical dilation and perform Leopolds maneuvers
E Determine gestational age of fetus
Stages of Labor First Stage
bull 0 to 10 cm dilatation--opening of cervix)bull Latent slowest part of the process--slow
dilation mild contractionsbull from onset of regular UCs to rapid
dilatation (about 3-4 cms)bull Active labor ldquopicks up steamrdquo--period of
more rapid dilationbull from 4 cm to full dilatation stronger UCsbull Transition 7-10 cm--intense NV shaking
EffacementThinning of cervix(in )
StationDescent of fetal head(in cm)
Descent offetal head
Station
Floating
Engaged
At outletcrowning
Dilatation amp Effacement
>
Care of Laboring PatientEarly Labor
bull Initial physical assessment amp history
bull Admission--rapportbull Fetal amp UC
monitoringbull Vaginal exams q 2
hoursbull Vital signsbull Temperature q 4
hours-intact or q 2 hours ROM
bull Educate regarding labor
bull Encourage comfort position changes bladder emptying
bull Assess pain pain tolerance preferred type of labordelivery
bull Reassure regarding what is normal reduce anxiety
Couple excited talkative pain is manageable
Care of Laboring Patient Active Labor
bull Transition (7-10 cm) Yikes ldquoout of controlrdquo shaking nauseavomiting sweating pain is intensebull Prepare for delivery
bull Second stage (Pushing)bull Educateinstruct regarding pushingbull Assess urge to push and fetal descentbull Encouragemotivate patient assess fatiguebull Monitor fetalmaternal response to pushing
bulge crowningbull Signs of imminent birth perineal bulging
Couple quieter discouraged pain increasing
Stages of LaborSecond Stage
bull Pushing amp descent of baby (STATION)bull Full dilatation (10 cm) to birth
bull Important NOT to push until full dilationbull Assessment Urge to push Rectal
pressurebull Push only with UCrsquosbull Crowning babyrsquos head is visible at the
Mechanisms of labor A B Descent C Internal rotation D Extension E External rotation
Head Rotation during Descent
>
Crowning
In the hospital
Alternative settings
Crowning
Stages of Labor Third Stage
bull Placental stage from birth to delivery of placenta
bull Placental separation from uterine wall (rise of fundus sudden gush of blood lengthening of umbilical cord)
bull Entire lining of uterus shedbull Expulsion of placenta
bull Normal blood loss 300-500 mLbull If placenta does not deliver spontaneously can
be delivered manuallybull Pitocin infusion started immediately post
delivery of placenta
Critical Thinkingbull
A client is admitted to the labor unit with contractions 2 to 3 minutes apart and lasting 60 to 90 seconds The client is apprehensive and vomiting This nurse understands this information to indicate that the client is most likely in what phase of labor
bull A) Active bull B) Transition bull C) Latent bull D) Second
bull Stop pitocinbull Reposition to left lateral Trendelenberg if neededbull Oxygen via mask at 8-10 Lminbull Increase IV fluidsbull SQ terbutaline (025 mg) if uterus not relaxingbull Vaginal exam for possible cause prolapse fetal
descent rupture abruptionbull Amnioinfusion for variable decelsbull Notify MDmidwife
Which strip shows signs thatImmediate intervention is needed Why What would you do
A
B
Experiences of Pain
bull Etiology bull Physiologybull Perception
bull Factors influencingAnxiety Psychological factorsExpectations Cultural factors
Support Fetal position
Comfort and Pain Relief
bull Support from doula or coachbull Alternative therapies
bullRelaxationmassagebull Focusing and imagerybullBreathingbullHerbal preparationsaromatherapybullHypnosis
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Induction
bull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessment
bull Bishop Score- rating that determines if the cervix is ready for induction--Pg 765
bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole
-Inadequate uterine relaxation between contractions
lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveries
bull Forcepsbull Indications unable to push arrested descent need a
quick delivery breechbull Associated with maternalfetal birth trauma rectal
sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina
Cervix returns to firm nongravid consistency by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum
Assessment turn pt to side in Simrsquos position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy
Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments
Constipation Give stool softeners as ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis
Superficial leg vein diseasendash Ss tenderness in portion of vein local heat amp
redness normal temperature or low-grade feverndash Tx local heat elevate limb bed rest analgesia
elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation
Engorgement day 3 or 4ndash If breastfeeding
Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions
Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Chapter 22--Processes amp Stages of Labor and Birth
Critical Factors In Labor
Passenger
Slide 4
Slide 5
Fetal Lie and Presentation
Slide 7
Passenger (2)
Powers
Onset of labor
False vs True Labor Contractions
False vs True Labor Cervix
Critical Thinking
Stages of Labor First Stage
Slide 15
Slide 16
Slide 17
Dilatation amp Effacement
Care of Laboring Patient Early Labor
Care of Laboring Patient Active Labor
Stages of Labor Second Stage
Slide 22
Head Rotation during Descent
Slide 24
Stages of Labor Third Stage
Critical Thinking (2)
Chapter 23 Intrapartal Nursing Assessment
Initial Intrapartum Assessment Pages 608-612
Intrauterine Fetal Resuscitation
Slide 30
Experiences of Pain
Comfort and Pain Relief
Comfort and Pain Relief (2)
Systemic Analgesia Table 25-3 pg 690
Regional Anesthesia
Slide 36
Medication for Pain Relief Birth
Local anesthesia for Episiotomy
Childbirth at Risk (Ch 26)
Critical Thinking (3)
Precipitous Labor amp Birth
Postterm Pregnancy
Malpresentations
Malpresentations (cont)
External Version
MacrosomiaShoulder Dystocia
Slide 47
McRoberts Maneuvers Video
Multiple Gestation
Multiple Gestation (cont)
Abruptio Placentae
Slide 52
Abruptio Placentae (cont)
Placenta Previa
Slide 55
Prolapsed Cord
Prolapsed Cord (2)
Birth Related Procedures Chapter 27
Methods of Induction
Indications for induction of labor
Contraindications to Induction
Cervical Ripening Assessment
Oxytocin Induction pg 767
When to Discontinue Oxytocin
Operative Assisted Deliveries
Slide 66
Cesarean Birth Indications for
Cesarean Birth (cont)
Slide 69
Cesarean Birth
Post-Op Care
Critical Thinking (4)
POSTPARTUM CARE
Slide 74
Postpartum Psychological Adaptations Reva Rubin
Maternal Responses to Newborn Reva Rubin
Blues vs Dpression
Endocrine Adaptations
Physiological Adaptations
Slide 80
Fundal Assessment
Slide 82
Lochia
Lochia Assessment
Lochia Assessment (2)
Cervix amp Vagina
Perineum
Episiotomy
Other Assessments
Thrombophlebitis
Urinary Retention
Vital Signs
Breast Assessment
Lactation
Discharge Instructions
Postpartum Complications
Hemorrhage
Hemorrhage (cont)
Hematomas
Postpartum Infection
Postpartum Infection (2)
Endometritis
Postpartum Infection (3)
Slide 104
Slide 105
Slide 107
Slide 108
Slide 109
Slide 110
Breastfeeding
Passengerbull Occiput Anterior (LOA amp ROA) most
common positions amp easiest for birth
bull Occiput Posterior (LOP amp ROP) bull can prolong both 1st amp 2nd stage of laborbull back pain during UCs (back labor)bull Instruct partner in sacral pressure during UCrsquosbull Try ldquoall foursrdquo knee-chest or alternate side-
lying positions to encourage baby to rotate to anterior position
Powersbull Contractions supplied by fundus of uterus
bull Involuntary become stronger as labor progresses
bull Abdominal muscles ldquopushingrdquo by mom (2nd stage)
Psychebull Psychological state amp feelings of mom
bull Coping skillsbull Anxiety fear stressbull Labor support
Onset of laborbull Usually begins between 38 amp 42 weeksbull Mechanism is unknownbull Upper uterus contracts downward pushing
presenting part on cervix causing effacement and dilatation
bull Premonitory signs of laborbull Lightening Braxton-Hicks contractions (false
labor)bull cervical changes (ripening) bull bloody show (mucous plug) bull rupture of membranes (ROM) bull sudden burst of energy
False vs True Labor Contractions
False Labor
bull Benign and irregular contractions
bull Felt first abdominally and remain confined to the abdomen and groin
bull Often disappear with ambulation and sleep
bull Do not increase in duration frequency or intensity
True Laborbull Begin irregularly but
become regular and predictable
bull Felt first in lower back and sweep around to the abdomen in a wave
bull Continue no matter what the womenrsquos level of activity
bull Increase in duration frequency and intensity
False vs True Labor Cervix
False Laborbull No significant
change in dilation or effacement
bull No significant bloody show
bull Fetus- presenting part is not engaged in pelvis
True Laborbull Progressive
change in dilation and effacement
bull Bloody show
bull Presenting part engages in pelvis
Critical Thinkingbull A primigravida client has just arrived in the birthing
unit What steps would be most important for the nurse to perform to gain an understanding of the physical status of the client and her fetus
A Check for ruptured membranes and apply a fetal scalp electrode
B Auscultate the fetal heart rate between and during contractions
C Palpate contractions and resting uterine tone
D Perform a vaginal exam for cervical dilation and perform Leopolds maneuvers
E Determine gestational age of fetus
Stages of Labor First Stage
bull 0 to 10 cm dilatation--opening of cervix)bull Latent slowest part of the process--slow
dilation mild contractionsbull from onset of regular UCs to rapid
dilatation (about 3-4 cms)bull Active labor ldquopicks up steamrdquo--period of
more rapid dilationbull from 4 cm to full dilatation stronger UCsbull Transition 7-10 cm--intense NV shaking
EffacementThinning of cervix(in )
StationDescent of fetal head(in cm)
Descent offetal head
Station
Floating
Engaged
At outletcrowning
Dilatation amp Effacement
>
Care of Laboring PatientEarly Labor
bull Initial physical assessment amp history
bull Admission--rapportbull Fetal amp UC
monitoringbull Vaginal exams q 2
hoursbull Vital signsbull Temperature q 4
hours-intact or q 2 hours ROM
bull Educate regarding labor
bull Encourage comfort position changes bladder emptying
bull Assess pain pain tolerance preferred type of labordelivery
bull Reassure regarding what is normal reduce anxiety
Couple excited talkative pain is manageable
Care of Laboring Patient Active Labor
bull Transition (7-10 cm) Yikes ldquoout of controlrdquo shaking nauseavomiting sweating pain is intensebull Prepare for delivery
bull Second stage (Pushing)bull Educateinstruct regarding pushingbull Assess urge to push and fetal descentbull Encouragemotivate patient assess fatiguebull Monitor fetalmaternal response to pushing
bulge crowningbull Signs of imminent birth perineal bulging
Couple quieter discouraged pain increasing
Stages of LaborSecond Stage
bull Pushing amp descent of baby (STATION)bull Full dilatation (10 cm) to birth
bull Important NOT to push until full dilationbull Assessment Urge to push Rectal
pressurebull Push only with UCrsquosbull Crowning babyrsquos head is visible at the
Mechanisms of labor A B Descent C Internal rotation D Extension E External rotation
Head Rotation during Descent
>
Crowning
In the hospital
Alternative settings
Crowning
Stages of Labor Third Stage
bull Placental stage from birth to delivery of placenta
bull Placental separation from uterine wall (rise of fundus sudden gush of blood lengthening of umbilical cord)
bull Entire lining of uterus shedbull Expulsion of placenta
bull Normal blood loss 300-500 mLbull If placenta does not deliver spontaneously can
be delivered manuallybull Pitocin infusion started immediately post
delivery of placenta
Critical Thinkingbull
A client is admitted to the labor unit with contractions 2 to 3 minutes apart and lasting 60 to 90 seconds The client is apprehensive and vomiting This nurse understands this information to indicate that the client is most likely in what phase of labor
bull A) Active bull B) Transition bull C) Latent bull D) Second
bull Stop pitocinbull Reposition to left lateral Trendelenberg if neededbull Oxygen via mask at 8-10 Lminbull Increase IV fluidsbull SQ terbutaline (025 mg) if uterus not relaxingbull Vaginal exam for possible cause prolapse fetal
descent rupture abruptionbull Amnioinfusion for variable decelsbull Notify MDmidwife
Which strip shows signs thatImmediate intervention is needed Why What would you do
A
B
Experiences of Pain
bull Etiology bull Physiologybull Perception
bull Factors influencingAnxiety Psychological factorsExpectations Cultural factors
Support Fetal position
Comfort and Pain Relief
bull Support from doula or coachbull Alternative therapies
bullRelaxationmassagebull Focusing and imagerybullBreathingbullHerbal preparationsaromatherapybullHypnosis
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Induction
bull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessment
bull Bishop Score- rating that determines if the cervix is ready for induction--Pg 765
bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole
-Inadequate uterine relaxation between contractions
lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveries
bull Forcepsbull Indications unable to push arrested descent need a
quick delivery breechbull Associated with maternalfetal birth trauma rectal
sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina
Cervix returns to firm nongravid consistency by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum
Assessment turn pt to side in Simrsquos position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy
Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments
Constipation Give stool softeners as ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis
Superficial leg vein diseasendash Ss tenderness in portion of vein local heat amp
redness normal temperature or low-grade feverndash Tx local heat elevate limb bed rest analgesia
elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation
Engorgement day 3 or 4ndash If breastfeeding
Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions
Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Mechanisms of labor A B Descent C Internal rotation D Extension E External rotation
Head Rotation during Descent
>
Crowning
In the hospital
Alternative settings
Crowning
Stages of Labor Third Stage
bull Placental stage from birth to delivery of placenta
bull Placental separation from uterine wall (rise of fundus sudden gush of blood lengthening of umbilical cord)
bull Entire lining of uterus shedbull Expulsion of placenta
bull Normal blood loss 300-500 mLbull If placenta does not deliver spontaneously can
be delivered manuallybull Pitocin infusion started immediately post
delivery of placenta
Critical Thinkingbull
A client is admitted to the labor unit with contractions 2 to 3 minutes apart and lasting 60 to 90 seconds The client is apprehensive and vomiting This nurse understands this information to indicate that the client is most likely in what phase of labor
bull A) Active bull B) Transition bull C) Latent bull D) Second
bull Stop pitocinbull Reposition to left lateral Trendelenberg if neededbull Oxygen via mask at 8-10 Lminbull Increase IV fluidsbull SQ terbutaline (025 mg) if uterus not relaxingbull Vaginal exam for possible cause prolapse fetal
descent rupture abruptionbull Amnioinfusion for variable decelsbull Notify MDmidwife
Which strip shows signs thatImmediate intervention is needed Why What would you do
A
B
Experiences of Pain
bull Etiology bull Physiologybull Perception
bull Factors influencingAnxiety Psychological factorsExpectations Cultural factors
Support Fetal position
Comfort and Pain Relief
bull Support from doula or coachbull Alternative therapies
bullRelaxationmassagebull Focusing and imagerybullBreathingbullHerbal preparationsaromatherapybullHypnosis
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Induction
bull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessment
bull Bishop Score- rating that determines if the cervix is ready for induction--Pg 765
bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole
-Inadequate uterine relaxation between contractions
lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveries
bull Forcepsbull Indications unable to push arrested descent need a
quick delivery breechbull Associated with maternalfetal birth trauma rectal
sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina
Cervix returns to firm nongravid consistency by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum
Assessment turn pt to side in Simrsquos position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy
Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments
Constipation Give stool softeners as ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis
Superficial leg vein diseasendash Ss tenderness in portion of vein local heat amp
redness normal temperature or low-grade feverndash Tx local heat elevate limb bed rest analgesia
elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation
Engorgement day 3 or 4ndash If breastfeeding
Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions
Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Mechanisms of labor A B Descent C Internal rotation D Extension E External rotation
Head Rotation during Descent
>
Crowning
In the hospital
Alternative settings
Crowning
Stages of Labor Third Stage
bull Placental stage from birth to delivery of placenta
bull Placental separation from uterine wall (rise of fundus sudden gush of blood lengthening of umbilical cord)
bull Entire lining of uterus shedbull Expulsion of placenta
bull Normal blood loss 300-500 mLbull If placenta does not deliver spontaneously can
be delivered manuallybull Pitocin infusion started immediately post
delivery of placenta
Critical Thinkingbull
A client is admitted to the labor unit with contractions 2 to 3 minutes apart and lasting 60 to 90 seconds The client is apprehensive and vomiting This nurse understands this information to indicate that the client is most likely in what phase of labor
bull A) Active bull B) Transition bull C) Latent bull D) Second
bull Stop pitocinbull Reposition to left lateral Trendelenberg if neededbull Oxygen via mask at 8-10 Lminbull Increase IV fluidsbull SQ terbutaline (025 mg) if uterus not relaxingbull Vaginal exam for possible cause prolapse fetal
descent rupture abruptionbull Amnioinfusion for variable decelsbull Notify MDmidwife
Which strip shows signs thatImmediate intervention is needed Why What would you do
A
B
Experiences of Pain
bull Etiology bull Physiologybull Perception
bull Factors influencingAnxiety Psychological factorsExpectations Cultural factors
Support Fetal position
Comfort and Pain Relief
bull Support from doula or coachbull Alternative therapies
bullRelaxationmassagebull Focusing and imagerybullBreathingbullHerbal preparationsaromatherapybullHypnosis
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Induction
bull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessment
bull Bishop Score- rating that determines if the cervix is ready for induction--Pg 765
bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole
-Inadequate uterine relaxation between contractions
lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveries
bull Forcepsbull Indications unable to push arrested descent need a
quick delivery breechbull Associated with maternalfetal birth trauma rectal
sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina
Cervix returns to firm nongravid consistency by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum
Assessment turn pt to side in Simrsquos position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy
Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments
Constipation Give stool softeners as ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis
Superficial leg vein diseasendash Ss tenderness in portion of vein local heat amp
redness normal temperature or low-grade feverndash Tx local heat elevate limb bed rest analgesia
elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation
Engorgement day 3 or 4ndash If breastfeeding
Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions
Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Mechanisms of labor A B Descent C Internal rotation D Extension E External rotation
Head Rotation during Descent
>
Crowning
In the hospital
Alternative settings
Crowning
Stages of Labor Third Stage
bull Placental stage from birth to delivery of placenta
bull Placental separation from uterine wall (rise of fundus sudden gush of blood lengthening of umbilical cord)
bull Entire lining of uterus shedbull Expulsion of placenta
bull Normal blood loss 300-500 mLbull If placenta does not deliver spontaneously can
be delivered manuallybull Pitocin infusion started immediately post
delivery of placenta
Critical Thinkingbull
A client is admitted to the labor unit with contractions 2 to 3 minutes apart and lasting 60 to 90 seconds The client is apprehensive and vomiting This nurse understands this information to indicate that the client is most likely in what phase of labor
bull A) Active bull B) Transition bull C) Latent bull D) Second
bull Stop pitocinbull Reposition to left lateral Trendelenberg if neededbull Oxygen via mask at 8-10 Lminbull Increase IV fluidsbull SQ terbutaline (025 mg) if uterus not relaxingbull Vaginal exam for possible cause prolapse fetal
descent rupture abruptionbull Amnioinfusion for variable decelsbull Notify MDmidwife
Which strip shows signs thatImmediate intervention is needed Why What would you do
A
B
Experiences of Pain
bull Etiology bull Physiologybull Perception
bull Factors influencingAnxiety Psychological factorsExpectations Cultural factors
Support Fetal position
Comfort and Pain Relief
bull Support from doula or coachbull Alternative therapies
bullRelaxationmassagebull Focusing and imagerybullBreathingbullHerbal preparationsaromatherapybullHypnosis
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Induction
bull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessment
bull Bishop Score- rating that determines if the cervix is ready for induction--Pg 765
bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole
-Inadequate uterine relaxation between contractions
lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveries
bull Forcepsbull Indications unable to push arrested descent need a
quick delivery breechbull Associated with maternalfetal birth trauma rectal
sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina
Cervix returns to firm nongravid consistency by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum
Assessment turn pt to side in Simrsquos position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy
Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments
Constipation Give stool softeners as ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis
Superficial leg vein diseasendash Ss tenderness in portion of vein local heat amp
redness normal temperature or low-grade feverndash Tx local heat elevate limb bed rest analgesia
elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation
Engorgement day 3 or 4ndash If breastfeeding
Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions
Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Mechanisms of labor A B Descent C Internal rotation D Extension E External rotation
Head Rotation during Descent
>
Crowning
In the hospital
Alternative settings
Crowning
Stages of Labor Third Stage
bull Placental stage from birth to delivery of placenta
bull Placental separation from uterine wall (rise of fundus sudden gush of blood lengthening of umbilical cord)
bull Entire lining of uterus shedbull Expulsion of placenta
bull Normal blood loss 300-500 mLbull If placenta does not deliver spontaneously can
be delivered manuallybull Pitocin infusion started immediately post
delivery of placenta
Critical Thinkingbull
A client is admitted to the labor unit with contractions 2 to 3 minutes apart and lasting 60 to 90 seconds The client is apprehensive and vomiting This nurse understands this information to indicate that the client is most likely in what phase of labor
bull A) Active bull B) Transition bull C) Latent bull D) Second
bull Stop pitocinbull Reposition to left lateral Trendelenberg if neededbull Oxygen via mask at 8-10 Lminbull Increase IV fluidsbull SQ terbutaline (025 mg) if uterus not relaxingbull Vaginal exam for possible cause prolapse fetal
descent rupture abruptionbull Amnioinfusion for variable decelsbull Notify MDmidwife
Which strip shows signs thatImmediate intervention is needed Why What would you do
A
B
Experiences of Pain
bull Etiology bull Physiologybull Perception
bull Factors influencingAnxiety Psychological factorsExpectations Cultural factors
Support Fetal position
Comfort and Pain Relief
bull Support from doula or coachbull Alternative therapies
bullRelaxationmassagebull Focusing and imagerybullBreathingbullHerbal preparationsaromatherapybullHypnosis
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Induction
bull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessment
bull Bishop Score- rating that determines if the cervix is ready for induction--Pg 765
bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole
-Inadequate uterine relaxation between contractions
lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveries
bull Forcepsbull Indications unable to push arrested descent need a
quick delivery breechbull Associated with maternalfetal birth trauma rectal
sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina
Cervix returns to firm nongravid consistency by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum
Assessment turn pt to side in Simrsquos position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy
Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments
Constipation Give stool softeners as ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis
Superficial leg vein diseasendash Ss tenderness in portion of vein local heat amp
redness normal temperature or low-grade feverndash Tx local heat elevate limb bed rest analgesia
elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation
Engorgement day 3 or 4ndash If breastfeeding
Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions
Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Mechanisms of labor A B Descent C Internal rotation D Extension E External rotation
Head Rotation during Descent
>
Crowning
In the hospital
Alternative settings
Crowning
Stages of Labor Third Stage
bull Placental stage from birth to delivery of placenta
bull Placental separation from uterine wall (rise of fundus sudden gush of blood lengthening of umbilical cord)
bull Entire lining of uterus shedbull Expulsion of placenta
bull Normal blood loss 300-500 mLbull If placenta does not deliver spontaneously can
be delivered manuallybull Pitocin infusion started immediately post
delivery of placenta
Critical Thinkingbull
A client is admitted to the labor unit with contractions 2 to 3 minutes apart and lasting 60 to 90 seconds The client is apprehensive and vomiting This nurse understands this information to indicate that the client is most likely in what phase of labor
bull A) Active bull B) Transition bull C) Latent bull D) Second
bull Stop pitocinbull Reposition to left lateral Trendelenberg if neededbull Oxygen via mask at 8-10 Lminbull Increase IV fluidsbull SQ terbutaline (025 mg) if uterus not relaxingbull Vaginal exam for possible cause prolapse fetal
descent rupture abruptionbull Amnioinfusion for variable decelsbull Notify MDmidwife
Which strip shows signs thatImmediate intervention is needed Why What would you do
A
B
Experiences of Pain
bull Etiology bull Physiologybull Perception
bull Factors influencingAnxiety Psychological factorsExpectations Cultural factors
Support Fetal position
Comfort and Pain Relief
bull Support from doula or coachbull Alternative therapies
bullRelaxationmassagebull Focusing and imagerybullBreathingbullHerbal preparationsaromatherapybullHypnosis
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Induction
bull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessment
bull Bishop Score- rating that determines if the cervix is ready for induction--Pg 765
bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole
-Inadequate uterine relaxation between contractions
lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveries
bull Forcepsbull Indications unable to push arrested descent need a
quick delivery breechbull Associated with maternalfetal birth trauma rectal
sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina
Cervix returns to firm nongravid consistency by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum
Assessment turn pt to side in Simrsquos position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy
Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments
Constipation Give stool softeners as ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis
Superficial leg vein diseasendash Ss tenderness in portion of vein local heat amp
redness normal temperature or low-grade feverndash Tx local heat elevate limb bed rest analgesia
elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation
Engorgement day 3 or 4ndash If breastfeeding
Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions
Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Mechanisms of labor A B Descent C Internal rotation D Extension E External rotation
Head Rotation during Descent
>
Crowning
In the hospital
Alternative settings
Crowning
Stages of Labor Third Stage
bull Placental stage from birth to delivery of placenta
bull Placental separation from uterine wall (rise of fundus sudden gush of blood lengthening of umbilical cord)
bull Entire lining of uterus shedbull Expulsion of placenta
bull Normal blood loss 300-500 mLbull If placenta does not deliver spontaneously can
be delivered manuallybull Pitocin infusion started immediately post
delivery of placenta
Critical Thinkingbull
A client is admitted to the labor unit with contractions 2 to 3 minutes apart and lasting 60 to 90 seconds The client is apprehensive and vomiting This nurse understands this information to indicate that the client is most likely in what phase of labor
bull A) Active bull B) Transition bull C) Latent bull D) Second
bull Stop pitocinbull Reposition to left lateral Trendelenberg if neededbull Oxygen via mask at 8-10 Lminbull Increase IV fluidsbull SQ terbutaline (025 mg) if uterus not relaxingbull Vaginal exam for possible cause prolapse fetal
descent rupture abruptionbull Amnioinfusion for variable decelsbull Notify MDmidwife
Which strip shows signs thatImmediate intervention is needed Why What would you do
A
B
Experiences of Pain
bull Etiology bull Physiologybull Perception
bull Factors influencingAnxiety Psychological factorsExpectations Cultural factors
Support Fetal position
Comfort and Pain Relief
bull Support from doula or coachbull Alternative therapies
bullRelaxationmassagebull Focusing and imagerybullBreathingbullHerbal preparationsaromatherapybullHypnosis
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Induction
bull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessment
bull Bishop Score- rating that determines if the cervix is ready for induction--Pg 765
bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole
-Inadequate uterine relaxation between contractions
lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveries
bull Forcepsbull Indications unable to push arrested descent need a
quick delivery breechbull Associated with maternalfetal birth trauma rectal
sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina
Cervix returns to firm nongravid consistency by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum
Assessment turn pt to side in Simrsquos position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy
Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments
Constipation Give stool softeners as ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis
Superficial leg vein diseasendash Ss tenderness in portion of vein local heat amp
redness normal temperature or low-grade feverndash Tx local heat elevate limb bed rest analgesia
elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation
Engorgement day 3 or 4ndash If breastfeeding
Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions
Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Mechanisms of labor A B Descent C Internal rotation D Extension E External rotation
Head Rotation during Descent
>
Crowning
In the hospital
Alternative settings
Crowning
Stages of Labor Third Stage
bull Placental stage from birth to delivery of placenta
bull Placental separation from uterine wall (rise of fundus sudden gush of blood lengthening of umbilical cord)
bull Entire lining of uterus shedbull Expulsion of placenta
bull Normal blood loss 300-500 mLbull If placenta does not deliver spontaneously can
be delivered manuallybull Pitocin infusion started immediately post
delivery of placenta
Critical Thinkingbull
A client is admitted to the labor unit with contractions 2 to 3 minutes apart and lasting 60 to 90 seconds The client is apprehensive and vomiting This nurse understands this information to indicate that the client is most likely in what phase of labor
bull A) Active bull B) Transition bull C) Latent bull D) Second
bull Stop pitocinbull Reposition to left lateral Trendelenberg if neededbull Oxygen via mask at 8-10 Lminbull Increase IV fluidsbull SQ terbutaline (025 mg) if uterus not relaxingbull Vaginal exam for possible cause prolapse fetal
descent rupture abruptionbull Amnioinfusion for variable decelsbull Notify MDmidwife
Which strip shows signs thatImmediate intervention is needed Why What would you do
A
B
Experiences of Pain
bull Etiology bull Physiologybull Perception
bull Factors influencingAnxiety Psychological factorsExpectations Cultural factors
Support Fetal position
Comfort and Pain Relief
bull Support from doula or coachbull Alternative therapies
bullRelaxationmassagebull Focusing and imagerybullBreathingbullHerbal preparationsaromatherapybullHypnosis
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Induction
bull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessment
bull Bishop Score- rating that determines if the cervix is ready for induction--Pg 765
bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole
-Inadequate uterine relaxation between contractions
lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveries
bull Forcepsbull Indications unable to push arrested descent need a
quick delivery breechbull Associated with maternalfetal birth trauma rectal
sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina
Cervix returns to firm nongravid consistency by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum
Assessment turn pt to side in Simrsquos position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy
Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments
Constipation Give stool softeners as ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis
Superficial leg vein diseasendash Ss tenderness in portion of vein local heat amp
redness normal temperature or low-grade feverndash Tx local heat elevate limb bed rest analgesia
elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation
Engorgement day 3 or 4ndash If breastfeeding
Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions
Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Mechanisms of labor A B Descent C Internal rotation D Extension E External rotation
Head Rotation during Descent
>
Crowning
In the hospital
Alternative settings
Crowning
Stages of Labor Third Stage
bull Placental stage from birth to delivery of placenta
bull Placental separation from uterine wall (rise of fundus sudden gush of blood lengthening of umbilical cord)
bull Entire lining of uterus shedbull Expulsion of placenta
bull Normal blood loss 300-500 mLbull If placenta does not deliver spontaneously can
be delivered manuallybull Pitocin infusion started immediately post
delivery of placenta
Critical Thinkingbull
A client is admitted to the labor unit with contractions 2 to 3 minutes apart and lasting 60 to 90 seconds The client is apprehensive and vomiting This nurse understands this information to indicate that the client is most likely in what phase of labor
bull A) Active bull B) Transition bull C) Latent bull D) Second
bull Stop pitocinbull Reposition to left lateral Trendelenberg if neededbull Oxygen via mask at 8-10 Lminbull Increase IV fluidsbull SQ terbutaline (025 mg) if uterus not relaxingbull Vaginal exam for possible cause prolapse fetal
descent rupture abruptionbull Amnioinfusion for variable decelsbull Notify MDmidwife
Which strip shows signs thatImmediate intervention is needed Why What would you do
A
B
Experiences of Pain
bull Etiology bull Physiologybull Perception
bull Factors influencingAnxiety Psychological factorsExpectations Cultural factors
Support Fetal position
Comfort and Pain Relief
bull Support from doula or coachbull Alternative therapies
bullRelaxationmassagebull Focusing and imagerybullBreathingbullHerbal preparationsaromatherapybullHypnosis
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Induction
bull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessment
bull Bishop Score- rating that determines if the cervix is ready for induction--Pg 765
bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole
-Inadequate uterine relaxation between contractions
lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveries
bull Forcepsbull Indications unable to push arrested descent need a
quick delivery breechbull Associated with maternalfetal birth trauma rectal
sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina
Cervix returns to firm nongravid consistency by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum
Assessment turn pt to side in Simrsquos position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy
Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments
Constipation Give stool softeners as ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis
Superficial leg vein diseasendash Ss tenderness in portion of vein local heat amp
redness normal temperature or low-grade feverndash Tx local heat elevate limb bed rest analgesia
elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation
Engorgement day 3 or 4ndash If breastfeeding
Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions
Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Mechanisms of labor A B Descent C Internal rotation D Extension E External rotation
Head Rotation during Descent
>
Crowning
In the hospital
Alternative settings
Crowning
Stages of Labor Third Stage
bull Placental stage from birth to delivery of placenta
bull Placental separation from uterine wall (rise of fundus sudden gush of blood lengthening of umbilical cord)
bull Entire lining of uterus shedbull Expulsion of placenta
bull Normal blood loss 300-500 mLbull If placenta does not deliver spontaneously can
be delivered manuallybull Pitocin infusion started immediately post
delivery of placenta
Critical Thinkingbull
A client is admitted to the labor unit with contractions 2 to 3 minutes apart and lasting 60 to 90 seconds The client is apprehensive and vomiting This nurse understands this information to indicate that the client is most likely in what phase of labor
bull A) Active bull B) Transition bull C) Latent bull D) Second
bull Stop pitocinbull Reposition to left lateral Trendelenberg if neededbull Oxygen via mask at 8-10 Lminbull Increase IV fluidsbull SQ terbutaline (025 mg) if uterus not relaxingbull Vaginal exam for possible cause prolapse fetal
descent rupture abruptionbull Amnioinfusion for variable decelsbull Notify MDmidwife
Which strip shows signs thatImmediate intervention is needed Why What would you do
A
B
Experiences of Pain
bull Etiology bull Physiologybull Perception
bull Factors influencingAnxiety Psychological factorsExpectations Cultural factors
Support Fetal position
Comfort and Pain Relief
bull Support from doula or coachbull Alternative therapies
bullRelaxationmassagebull Focusing and imagerybullBreathingbullHerbal preparationsaromatherapybullHypnosis
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Induction
bull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessment
bull Bishop Score- rating that determines if the cervix is ready for induction--Pg 765
bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole
-Inadequate uterine relaxation between contractions
lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveries
bull Forcepsbull Indications unable to push arrested descent need a
quick delivery breechbull Associated with maternalfetal birth trauma rectal
sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina
Cervix returns to firm nongravid consistency by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum
Assessment turn pt to side in Simrsquos position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy
Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments
Constipation Give stool softeners as ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis
Superficial leg vein diseasendash Ss tenderness in portion of vein local heat amp
redness normal temperature or low-grade feverndash Tx local heat elevate limb bed rest analgesia
elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation
Engorgement day 3 or 4ndash If breastfeeding
Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions
Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Mechanisms of labor A B Descent C Internal rotation D Extension E External rotation
Head Rotation during Descent
>
Crowning
In the hospital
Alternative settings
Crowning
Stages of Labor Third Stage
bull Placental stage from birth to delivery of placenta
bull Placental separation from uterine wall (rise of fundus sudden gush of blood lengthening of umbilical cord)
bull Entire lining of uterus shedbull Expulsion of placenta
bull Normal blood loss 300-500 mLbull If placenta does not deliver spontaneously can
be delivered manuallybull Pitocin infusion started immediately post
delivery of placenta
Critical Thinkingbull
A client is admitted to the labor unit with contractions 2 to 3 minutes apart and lasting 60 to 90 seconds The client is apprehensive and vomiting This nurse understands this information to indicate that the client is most likely in what phase of labor
bull A) Active bull B) Transition bull C) Latent bull D) Second
bull Stop pitocinbull Reposition to left lateral Trendelenberg if neededbull Oxygen via mask at 8-10 Lminbull Increase IV fluidsbull SQ terbutaline (025 mg) if uterus not relaxingbull Vaginal exam for possible cause prolapse fetal
descent rupture abruptionbull Amnioinfusion for variable decelsbull Notify MDmidwife
Which strip shows signs thatImmediate intervention is needed Why What would you do
A
B
Experiences of Pain
bull Etiology bull Physiologybull Perception
bull Factors influencingAnxiety Psychological factorsExpectations Cultural factors
Support Fetal position
Comfort and Pain Relief
bull Support from doula or coachbull Alternative therapies
bullRelaxationmassagebull Focusing and imagerybullBreathingbullHerbal preparationsaromatherapybullHypnosis
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Induction
bull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessment
bull Bishop Score- rating that determines if the cervix is ready for induction--Pg 765
bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole
-Inadequate uterine relaxation between contractions
lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveries
bull Forcepsbull Indications unable to push arrested descent need a
quick delivery breechbull Associated with maternalfetal birth trauma rectal
sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina
Cervix returns to firm nongravid consistency by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum
Assessment turn pt to side in Simrsquos position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy
Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments
Constipation Give stool softeners as ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis
Superficial leg vein diseasendash Ss tenderness in portion of vein local heat amp
redness normal temperature or low-grade feverndash Tx local heat elevate limb bed rest analgesia
elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation
Engorgement day 3 or 4ndash If breastfeeding
Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions
Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Mechanisms of labor A B Descent C Internal rotation D Extension E External rotation
Head Rotation during Descent
>
Crowning
In the hospital
Alternative settings
Crowning
Stages of Labor Third Stage
bull Placental stage from birth to delivery of placenta
bull Placental separation from uterine wall (rise of fundus sudden gush of blood lengthening of umbilical cord)
bull Entire lining of uterus shedbull Expulsion of placenta
bull Normal blood loss 300-500 mLbull If placenta does not deliver spontaneously can
be delivered manuallybull Pitocin infusion started immediately post
delivery of placenta
Critical Thinkingbull
A client is admitted to the labor unit with contractions 2 to 3 minutes apart and lasting 60 to 90 seconds The client is apprehensive and vomiting This nurse understands this information to indicate that the client is most likely in what phase of labor
bull A) Active bull B) Transition bull C) Latent bull D) Second
bull Stop pitocinbull Reposition to left lateral Trendelenberg if neededbull Oxygen via mask at 8-10 Lminbull Increase IV fluidsbull SQ terbutaline (025 mg) if uterus not relaxingbull Vaginal exam for possible cause prolapse fetal
descent rupture abruptionbull Amnioinfusion for variable decelsbull Notify MDmidwife
Which strip shows signs thatImmediate intervention is needed Why What would you do
A
B
Experiences of Pain
bull Etiology bull Physiologybull Perception
bull Factors influencingAnxiety Psychological factorsExpectations Cultural factors
Support Fetal position
Comfort and Pain Relief
bull Support from doula or coachbull Alternative therapies
bullRelaxationmassagebull Focusing and imagerybullBreathingbullHerbal preparationsaromatherapybullHypnosis
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Induction
bull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessment
bull Bishop Score- rating that determines if the cervix is ready for induction--Pg 765
bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole
-Inadequate uterine relaxation between contractions
lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveries
bull Forcepsbull Indications unable to push arrested descent need a
quick delivery breechbull Associated with maternalfetal birth trauma rectal
sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina
Cervix returns to firm nongravid consistency by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum
Assessment turn pt to side in Simrsquos position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy
Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments
Constipation Give stool softeners as ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis
Superficial leg vein diseasendash Ss tenderness in portion of vein local heat amp
redness normal temperature or low-grade feverndash Tx local heat elevate limb bed rest analgesia
elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation
Engorgement day 3 or 4ndash If breastfeeding
Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions
Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Mechanisms of labor A B Descent C Internal rotation D Extension E External rotation
Head Rotation during Descent
>
Crowning
In the hospital
Alternative settings
Crowning
Stages of Labor Third Stage
bull Placental stage from birth to delivery of placenta
bull Placental separation from uterine wall (rise of fundus sudden gush of blood lengthening of umbilical cord)
bull Entire lining of uterus shedbull Expulsion of placenta
bull Normal blood loss 300-500 mLbull If placenta does not deliver spontaneously can
be delivered manuallybull Pitocin infusion started immediately post
delivery of placenta
Critical Thinkingbull
A client is admitted to the labor unit with contractions 2 to 3 minutes apart and lasting 60 to 90 seconds The client is apprehensive and vomiting This nurse understands this information to indicate that the client is most likely in what phase of labor
bull A) Active bull B) Transition bull C) Latent bull D) Second
bull Stop pitocinbull Reposition to left lateral Trendelenberg if neededbull Oxygen via mask at 8-10 Lminbull Increase IV fluidsbull SQ terbutaline (025 mg) if uterus not relaxingbull Vaginal exam for possible cause prolapse fetal
descent rupture abruptionbull Amnioinfusion for variable decelsbull Notify MDmidwife
Which strip shows signs thatImmediate intervention is needed Why What would you do
A
B
Experiences of Pain
bull Etiology bull Physiologybull Perception
bull Factors influencingAnxiety Psychological factorsExpectations Cultural factors
Support Fetal position
Comfort and Pain Relief
bull Support from doula or coachbull Alternative therapies
bullRelaxationmassagebull Focusing and imagerybullBreathingbullHerbal preparationsaromatherapybullHypnosis
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Induction
bull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessment
bull Bishop Score- rating that determines if the cervix is ready for induction--Pg 765
bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole
-Inadequate uterine relaxation between contractions
lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveries
bull Forcepsbull Indications unable to push arrested descent need a
quick delivery breechbull Associated with maternalfetal birth trauma rectal
sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina
Cervix returns to firm nongravid consistency by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum
Assessment turn pt to side in Simrsquos position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy
Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments
Constipation Give stool softeners as ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis
Superficial leg vein diseasendash Ss tenderness in portion of vein local heat amp
redness normal temperature or low-grade feverndash Tx local heat elevate limb bed rest analgesia
elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation
Engorgement day 3 or 4ndash If breastfeeding
Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions
Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Chapter 22--Processes amp Stages of Labor and Birth
Critical Factors In Labor
Passenger
Slide 4
Slide 5
Fetal Lie and Presentation
Slide 7
Passenger (2)
Powers
Onset of labor
False vs True Labor Contractions
False vs True Labor Cervix
Critical Thinking
Stages of Labor First Stage
Slide 15
Slide 16
Slide 17
Dilatation amp Effacement
Care of Laboring Patient Early Labor
Care of Laboring Patient Active Labor
Stages of Labor Second Stage
Slide 22
Head Rotation during Descent
Slide 24
Stages of Labor Third Stage
Critical Thinking (2)
Chapter 23 Intrapartal Nursing Assessment
Initial Intrapartum Assessment Pages 608-612
Intrauterine Fetal Resuscitation
Slide 30
Experiences of Pain
Comfort and Pain Relief
Comfort and Pain Relief (2)
Systemic Analgesia Table 25-3 pg 690
Regional Anesthesia
Slide 36
Medication for Pain Relief Birth
Local anesthesia for Episiotomy
Childbirth at Risk (Ch 26)
Critical Thinking (3)
Precipitous Labor amp Birth
Postterm Pregnancy
Malpresentations
Malpresentations (cont)
External Version
MacrosomiaShoulder Dystocia
Slide 47
McRoberts Maneuvers Video
Multiple Gestation
Multiple Gestation (cont)
Abruptio Placentae
Slide 52
Abruptio Placentae (cont)
Placenta Previa
Slide 55
Prolapsed Cord
Prolapsed Cord (2)
Birth Related Procedures Chapter 27
Methods of Induction
Indications for induction of labor
Contraindications to Induction
Cervical Ripening Assessment
Oxytocin Induction pg 767
When to Discontinue Oxytocin
Operative Assisted Deliveries
Slide 66
Cesarean Birth Indications for
Cesarean Birth (cont)
Slide 69
Cesarean Birth
Post-Op Care
Critical Thinking (4)
POSTPARTUM CARE
Slide 74
Postpartum Psychological Adaptations Reva Rubin
Maternal Responses to Newborn Reva Rubin
Blues vs Dpression
Endocrine Adaptations
Physiological Adaptations
Slide 80
Fundal Assessment
Slide 82
Lochia
Lochia Assessment
Lochia Assessment (2)
Cervix amp Vagina
Perineum
Episiotomy
Other Assessments
Thrombophlebitis
Urinary Retention
Vital Signs
Breast Assessment
Lactation
Discharge Instructions
Postpartum Complications
Hemorrhage
Hemorrhage (cont)
Hematomas
Postpartum Infection
Postpartum Infection (2)
Endometritis
Postpartum Infection (3)
Slide 104
Slide 105
Slide 107
Slide 108
Slide 109
Slide 110
Breastfeeding
Mechanisms of labor A B Descent C Internal rotation D Extension E External rotation
Head Rotation during Descent
>
Crowning
In the hospital
Alternative settings
Crowning
Stages of Labor Third Stage
bull Placental stage from birth to delivery of placenta
bull Placental separation from uterine wall (rise of fundus sudden gush of blood lengthening of umbilical cord)
bull Entire lining of uterus shedbull Expulsion of placenta
bull Normal blood loss 300-500 mLbull If placenta does not deliver spontaneously can
be delivered manuallybull Pitocin infusion started immediately post
delivery of placenta
Critical Thinkingbull
A client is admitted to the labor unit with contractions 2 to 3 minutes apart and lasting 60 to 90 seconds The client is apprehensive and vomiting This nurse understands this information to indicate that the client is most likely in what phase of labor
bull A) Active bull B) Transition bull C) Latent bull D) Second
bull Stop pitocinbull Reposition to left lateral Trendelenberg if neededbull Oxygen via mask at 8-10 Lminbull Increase IV fluidsbull SQ terbutaline (025 mg) if uterus not relaxingbull Vaginal exam for possible cause prolapse fetal
descent rupture abruptionbull Amnioinfusion for variable decelsbull Notify MDmidwife
Which strip shows signs thatImmediate intervention is needed Why What would you do
A
B
Experiences of Pain
bull Etiology bull Physiologybull Perception
bull Factors influencingAnxiety Psychological factorsExpectations Cultural factors
Support Fetal position
Comfort and Pain Relief
bull Support from doula or coachbull Alternative therapies
bullRelaxationmassagebull Focusing and imagerybullBreathingbullHerbal preparationsaromatherapybullHypnosis
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Induction
bull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessment
bull Bishop Score- rating that determines if the cervix is ready for induction--Pg 765
bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole
-Inadequate uterine relaxation between contractions
lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveries
bull Forcepsbull Indications unable to push arrested descent need a
quick delivery breechbull Associated with maternalfetal birth trauma rectal
sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina
Cervix returns to firm nongravid consistency by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum
Assessment turn pt to side in Simrsquos position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy
Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments
Constipation Give stool softeners as ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis
Superficial leg vein diseasendash Ss tenderness in portion of vein local heat amp
redness normal temperature or low-grade feverndash Tx local heat elevate limb bed rest analgesia
elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation
Engorgement day 3 or 4ndash If breastfeeding
Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions
Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Chapter 22--Processes amp Stages of Labor and Birth
Critical Factors In Labor
Passenger
Slide 4
Slide 5
Fetal Lie and Presentation
Slide 7
Passenger (2)
Powers
Onset of labor
False vs True Labor Contractions
False vs True Labor Cervix
Critical Thinking
Stages of Labor First Stage
Slide 15
Slide 16
Slide 17
Dilatation amp Effacement
Care of Laboring Patient Early Labor
Care of Laboring Patient Active Labor
Stages of Labor Second Stage
Slide 22
Head Rotation during Descent
Slide 24
Stages of Labor Third Stage
Critical Thinking (2)
Chapter 23 Intrapartal Nursing Assessment
Initial Intrapartum Assessment Pages 608-612
Intrauterine Fetal Resuscitation
Slide 30
Experiences of Pain
Comfort and Pain Relief
Comfort and Pain Relief (2)
Systemic Analgesia Table 25-3 pg 690
Regional Anesthesia
Slide 36
Medication for Pain Relief Birth
Local anesthesia for Episiotomy
Childbirth at Risk (Ch 26)
Critical Thinking (3)
Precipitous Labor amp Birth
Postterm Pregnancy
Malpresentations
Malpresentations (cont)
External Version
MacrosomiaShoulder Dystocia
Slide 47
McRoberts Maneuvers Video
Multiple Gestation
Multiple Gestation (cont)
Abruptio Placentae
Slide 52
Abruptio Placentae (cont)
Placenta Previa
Slide 55
Prolapsed Cord
Prolapsed Cord (2)
Birth Related Procedures Chapter 27
Methods of Induction
Indications for induction of labor
Contraindications to Induction
Cervical Ripening Assessment
Oxytocin Induction pg 767
When to Discontinue Oxytocin
Operative Assisted Deliveries
Slide 66
Cesarean Birth Indications for
Cesarean Birth (cont)
Slide 69
Cesarean Birth
Post-Op Care
Critical Thinking (4)
POSTPARTUM CARE
Slide 74
Postpartum Psychological Adaptations Reva Rubin
Maternal Responses to Newborn Reva Rubin
Blues vs Dpression
Endocrine Adaptations
Physiological Adaptations
Slide 80
Fundal Assessment
Slide 82
Lochia
Lochia Assessment
Lochia Assessment (2)
Cervix amp Vagina
Perineum
Episiotomy
Other Assessments
Thrombophlebitis
Urinary Retention
Vital Signs
Breast Assessment
Lactation
Discharge Instructions
Postpartum Complications
Hemorrhage
Hemorrhage (cont)
Hematomas
Postpartum Infection
Postpartum Infection (2)
Endometritis
Postpartum Infection (3)
Slide 104
Slide 105
Slide 107
Slide 108
Slide 109
Slide 110
Breastfeeding
Head Rotation during Descent
>
Crowning
In the hospital
Alternative settings
Crowning
Stages of Labor Third Stage
bull Placental stage from birth to delivery of placenta
bull Placental separation from uterine wall (rise of fundus sudden gush of blood lengthening of umbilical cord)
bull Entire lining of uterus shedbull Expulsion of placenta
bull Normal blood loss 300-500 mLbull If placenta does not deliver spontaneously can
be delivered manuallybull Pitocin infusion started immediately post
delivery of placenta
Critical Thinkingbull
A client is admitted to the labor unit with contractions 2 to 3 minutes apart and lasting 60 to 90 seconds The client is apprehensive and vomiting This nurse understands this information to indicate that the client is most likely in what phase of labor
bull A) Active bull B) Transition bull C) Latent bull D) Second
bull Stop pitocinbull Reposition to left lateral Trendelenberg if neededbull Oxygen via mask at 8-10 Lminbull Increase IV fluidsbull SQ terbutaline (025 mg) if uterus not relaxingbull Vaginal exam for possible cause prolapse fetal
descent rupture abruptionbull Amnioinfusion for variable decelsbull Notify MDmidwife
Which strip shows signs thatImmediate intervention is needed Why What would you do
A
B
Experiences of Pain
bull Etiology bull Physiologybull Perception
bull Factors influencingAnxiety Psychological factorsExpectations Cultural factors
Support Fetal position
Comfort and Pain Relief
bull Support from doula or coachbull Alternative therapies
bullRelaxationmassagebull Focusing and imagerybullBreathingbullHerbal preparationsaromatherapybullHypnosis
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Induction
bull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessment
bull Bishop Score- rating that determines if the cervix is ready for induction--Pg 765
bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole
-Inadequate uterine relaxation between contractions
lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveries
bull Forcepsbull Indications unable to push arrested descent need a
quick delivery breechbull Associated with maternalfetal birth trauma rectal
sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina
Cervix returns to firm nongravid consistency by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum
Assessment turn pt to side in Simrsquos position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy
Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments
Constipation Give stool softeners as ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis
Superficial leg vein diseasendash Ss tenderness in portion of vein local heat amp
redness normal temperature or low-grade feverndash Tx local heat elevate limb bed rest analgesia
elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation
Engorgement day 3 or 4ndash If breastfeeding
Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions
Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Chapter 22--Processes amp Stages of Labor and Birth
Critical Factors In Labor
Passenger
Slide 4
Slide 5
Fetal Lie and Presentation
Slide 7
Passenger (2)
Powers
Onset of labor
False vs True Labor Contractions
False vs True Labor Cervix
Critical Thinking
Stages of Labor First Stage
Slide 15
Slide 16
Slide 17
Dilatation amp Effacement
Care of Laboring Patient Early Labor
Care of Laboring Patient Active Labor
Stages of Labor Second Stage
Slide 22
Head Rotation during Descent
Slide 24
Stages of Labor Third Stage
Critical Thinking (2)
Chapter 23 Intrapartal Nursing Assessment
Initial Intrapartum Assessment Pages 608-612
Intrauterine Fetal Resuscitation
Slide 30
Experiences of Pain
Comfort and Pain Relief
Comfort and Pain Relief (2)
Systemic Analgesia Table 25-3 pg 690
Regional Anesthesia
Slide 36
Medication for Pain Relief Birth
Local anesthesia for Episiotomy
Childbirth at Risk (Ch 26)
Critical Thinking (3)
Precipitous Labor amp Birth
Postterm Pregnancy
Malpresentations
Malpresentations (cont)
External Version
MacrosomiaShoulder Dystocia
Slide 47
McRoberts Maneuvers Video
Multiple Gestation
Multiple Gestation (cont)
Abruptio Placentae
Slide 52
Abruptio Placentae (cont)
Placenta Previa
Slide 55
Prolapsed Cord
Prolapsed Cord (2)
Birth Related Procedures Chapter 27
Methods of Induction
Indications for induction of labor
Contraindications to Induction
Cervical Ripening Assessment
Oxytocin Induction pg 767
When to Discontinue Oxytocin
Operative Assisted Deliveries
Slide 66
Cesarean Birth Indications for
Cesarean Birth (cont)
Slide 69
Cesarean Birth
Post-Op Care
Critical Thinking (4)
POSTPARTUM CARE
Slide 74
Postpartum Psychological Adaptations Reva Rubin
Maternal Responses to Newborn Reva Rubin
Blues vs Dpression
Endocrine Adaptations
Physiological Adaptations
Slide 80
Fundal Assessment
Slide 82
Lochia
Lochia Assessment
Lochia Assessment (2)
Cervix amp Vagina
Perineum
Episiotomy
Other Assessments
Thrombophlebitis
Urinary Retention
Vital Signs
Breast Assessment
Lactation
Discharge Instructions
Postpartum Complications
Hemorrhage
Hemorrhage (cont)
Hematomas
Postpartum Infection
Postpartum Infection (2)
Endometritis
Postpartum Infection (3)
Slide 104
Slide 105
Slide 107
Slide 108
Slide 109
Slide 110
Breastfeeding
Crowning
In the hospital
Alternative settings
Crowning
Stages of Labor Third Stage
bull Placental stage from birth to delivery of placenta
bull Placental separation from uterine wall (rise of fundus sudden gush of blood lengthening of umbilical cord)
bull Entire lining of uterus shedbull Expulsion of placenta
bull Normal blood loss 300-500 mLbull If placenta does not deliver spontaneously can
be delivered manuallybull Pitocin infusion started immediately post
delivery of placenta
Critical Thinkingbull
A client is admitted to the labor unit with contractions 2 to 3 minutes apart and lasting 60 to 90 seconds The client is apprehensive and vomiting This nurse understands this information to indicate that the client is most likely in what phase of labor
bull A) Active bull B) Transition bull C) Latent bull D) Second
bull Stop pitocinbull Reposition to left lateral Trendelenberg if neededbull Oxygen via mask at 8-10 Lminbull Increase IV fluidsbull SQ terbutaline (025 mg) if uterus not relaxingbull Vaginal exam for possible cause prolapse fetal
descent rupture abruptionbull Amnioinfusion for variable decelsbull Notify MDmidwife
Which strip shows signs thatImmediate intervention is needed Why What would you do
A
B
Experiences of Pain
bull Etiology bull Physiologybull Perception
bull Factors influencingAnxiety Psychological factorsExpectations Cultural factors
Support Fetal position
Comfort and Pain Relief
bull Support from doula or coachbull Alternative therapies
bullRelaxationmassagebull Focusing and imagerybullBreathingbullHerbal preparationsaromatherapybullHypnosis
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Induction
bull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessment
bull Bishop Score- rating that determines if the cervix is ready for induction--Pg 765
bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole
-Inadequate uterine relaxation between contractions
lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveries
bull Forcepsbull Indications unable to push arrested descent need a
quick delivery breechbull Associated with maternalfetal birth trauma rectal
sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina
Cervix returns to firm nongravid consistency by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum
Assessment turn pt to side in Simrsquos position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy
Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments
Constipation Give stool softeners as ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis
Superficial leg vein diseasendash Ss tenderness in portion of vein local heat amp
redness normal temperature or low-grade feverndash Tx local heat elevate limb bed rest analgesia
elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation
Engorgement day 3 or 4ndash If breastfeeding
Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions
Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Chapter 22--Processes amp Stages of Labor and Birth
Critical Factors In Labor
Passenger
Slide 4
Slide 5
Fetal Lie and Presentation
Slide 7
Passenger (2)
Powers
Onset of labor
False vs True Labor Contractions
False vs True Labor Cervix
Critical Thinking
Stages of Labor First Stage
Slide 15
Slide 16
Slide 17
Dilatation amp Effacement
Care of Laboring Patient Early Labor
Care of Laboring Patient Active Labor
Stages of Labor Second Stage
Slide 22
Head Rotation during Descent
Slide 24
Stages of Labor Third Stage
Critical Thinking (2)
Chapter 23 Intrapartal Nursing Assessment
Initial Intrapartum Assessment Pages 608-612
Intrauterine Fetal Resuscitation
Slide 30
Experiences of Pain
Comfort and Pain Relief
Comfort and Pain Relief (2)
Systemic Analgesia Table 25-3 pg 690
Regional Anesthesia
Slide 36
Medication for Pain Relief Birth
Local anesthesia for Episiotomy
Childbirth at Risk (Ch 26)
Critical Thinking (3)
Precipitous Labor amp Birth
Postterm Pregnancy
Malpresentations
Malpresentations (cont)
External Version
MacrosomiaShoulder Dystocia
Slide 47
McRoberts Maneuvers Video
Multiple Gestation
Multiple Gestation (cont)
Abruptio Placentae
Slide 52
Abruptio Placentae (cont)
Placenta Previa
Slide 55
Prolapsed Cord
Prolapsed Cord (2)
Birth Related Procedures Chapter 27
Methods of Induction
Indications for induction of labor
Contraindications to Induction
Cervical Ripening Assessment
Oxytocin Induction pg 767
When to Discontinue Oxytocin
Operative Assisted Deliveries
Slide 66
Cesarean Birth Indications for
Cesarean Birth (cont)
Slide 69
Cesarean Birth
Post-Op Care
Critical Thinking (4)
POSTPARTUM CARE
Slide 74
Postpartum Psychological Adaptations Reva Rubin
Maternal Responses to Newborn Reva Rubin
Blues vs Dpression
Endocrine Adaptations
Physiological Adaptations
Slide 80
Fundal Assessment
Slide 82
Lochia
Lochia Assessment
Lochia Assessment (2)
Cervix amp Vagina
Perineum
Episiotomy
Other Assessments
Thrombophlebitis
Urinary Retention
Vital Signs
Breast Assessment
Lactation
Discharge Instructions
Postpartum Complications
Hemorrhage
Hemorrhage (cont)
Hematomas
Postpartum Infection
Postpartum Infection (2)
Endometritis
Postpartum Infection (3)
Slide 104
Slide 105
Slide 107
Slide 108
Slide 109
Slide 110
Breastfeeding
Stages of Labor Third Stage
bull Placental stage from birth to delivery of placenta
bull Placental separation from uterine wall (rise of fundus sudden gush of blood lengthening of umbilical cord)
bull Entire lining of uterus shedbull Expulsion of placenta
bull Normal blood loss 300-500 mLbull If placenta does not deliver spontaneously can
be delivered manuallybull Pitocin infusion started immediately post
delivery of placenta
Critical Thinkingbull
A client is admitted to the labor unit with contractions 2 to 3 minutes apart and lasting 60 to 90 seconds The client is apprehensive and vomiting This nurse understands this information to indicate that the client is most likely in what phase of labor
bull A) Active bull B) Transition bull C) Latent bull D) Second
bull Stop pitocinbull Reposition to left lateral Trendelenberg if neededbull Oxygen via mask at 8-10 Lminbull Increase IV fluidsbull SQ terbutaline (025 mg) if uterus not relaxingbull Vaginal exam for possible cause prolapse fetal
descent rupture abruptionbull Amnioinfusion for variable decelsbull Notify MDmidwife
Which strip shows signs thatImmediate intervention is needed Why What would you do
A
B
Experiences of Pain
bull Etiology bull Physiologybull Perception
bull Factors influencingAnxiety Psychological factorsExpectations Cultural factors
Support Fetal position
Comfort and Pain Relief
bull Support from doula or coachbull Alternative therapies
bullRelaxationmassagebull Focusing and imagerybullBreathingbullHerbal preparationsaromatherapybullHypnosis
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Induction
bull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessment
bull Bishop Score- rating that determines if the cervix is ready for induction--Pg 765
bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole
-Inadequate uterine relaxation between contractions
lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveries
bull Forcepsbull Indications unable to push arrested descent need a
quick delivery breechbull Associated with maternalfetal birth trauma rectal
sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina
Cervix returns to firm nongravid consistency by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum
Assessment turn pt to side in Simrsquos position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy
Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments
Constipation Give stool softeners as ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis
Superficial leg vein diseasendash Ss tenderness in portion of vein local heat amp
redness normal temperature or low-grade feverndash Tx local heat elevate limb bed rest analgesia
elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation
Engorgement day 3 or 4ndash If breastfeeding
Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions
Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Chapter 22--Processes amp Stages of Labor and Birth
Critical Factors In Labor
Passenger
Slide 4
Slide 5
Fetal Lie and Presentation
Slide 7
Passenger (2)
Powers
Onset of labor
False vs True Labor Contractions
False vs True Labor Cervix
Critical Thinking
Stages of Labor First Stage
Slide 15
Slide 16
Slide 17
Dilatation amp Effacement
Care of Laboring Patient Early Labor
Care of Laboring Patient Active Labor
Stages of Labor Second Stage
Slide 22
Head Rotation during Descent
Slide 24
Stages of Labor Third Stage
Critical Thinking (2)
Chapter 23 Intrapartal Nursing Assessment
Initial Intrapartum Assessment Pages 608-612
Intrauterine Fetal Resuscitation
Slide 30
Experiences of Pain
Comfort and Pain Relief
Comfort and Pain Relief (2)
Systemic Analgesia Table 25-3 pg 690
Regional Anesthesia
Slide 36
Medication for Pain Relief Birth
Local anesthesia for Episiotomy
Childbirth at Risk (Ch 26)
Critical Thinking (3)
Precipitous Labor amp Birth
Postterm Pregnancy
Malpresentations
Malpresentations (cont)
External Version
MacrosomiaShoulder Dystocia
Slide 47
McRoberts Maneuvers Video
Multiple Gestation
Multiple Gestation (cont)
Abruptio Placentae
Slide 52
Abruptio Placentae (cont)
Placenta Previa
Slide 55
Prolapsed Cord
Prolapsed Cord (2)
Birth Related Procedures Chapter 27
Methods of Induction
Indications for induction of labor
Contraindications to Induction
Cervical Ripening Assessment
Oxytocin Induction pg 767
When to Discontinue Oxytocin
Operative Assisted Deliveries
Slide 66
Cesarean Birth Indications for
Cesarean Birth (cont)
Slide 69
Cesarean Birth
Post-Op Care
Critical Thinking (4)
POSTPARTUM CARE
Slide 74
Postpartum Psychological Adaptations Reva Rubin
Maternal Responses to Newborn Reva Rubin
Blues vs Dpression
Endocrine Adaptations
Physiological Adaptations
Slide 80
Fundal Assessment
Slide 82
Lochia
Lochia Assessment
Lochia Assessment (2)
Cervix amp Vagina
Perineum
Episiotomy
Other Assessments
Thrombophlebitis
Urinary Retention
Vital Signs
Breast Assessment
Lactation
Discharge Instructions
Postpartum Complications
Hemorrhage
Hemorrhage (cont)
Hematomas
Postpartum Infection
Postpartum Infection (2)
Endometritis
Postpartum Infection (3)
Slide 104
Slide 105
Slide 107
Slide 108
Slide 109
Slide 110
Breastfeeding
Critical Thinkingbull
A client is admitted to the labor unit with contractions 2 to 3 minutes apart and lasting 60 to 90 seconds The client is apprehensive and vomiting This nurse understands this information to indicate that the client is most likely in what phase of labor
bull A) Active bull B) Transition bull C) Latent bull D) Second
bull Stop pitocinbull Reposition to left lateral Trendelenberg if neededbull Oxygen via mask at 8-10 Lminbull Increase IV fluidsbull SQ terbutaline (025 mg) if uterus not relaxingbull Vaginal exam for possible cause prolapse fetal
descent rupture abruptionbull Amnioinfusion for variable decelsbull Notify MDmidwife
Which strip shows signs thatImmediate intervention is needed Why What would you do
A
B
Experiences of Pain
bull Etiology bull Physiologybull Perception
bull Factors influencingAnxiety Psychological factorsExpectations Cultural factors
Support Fetal position
Comfort and Pain Relief
bull Support from doula or coachbull Alternative therapies
bullRelaxationmassagebull Focusing and imagerybullBreathingbullHerbal preparationsaromatherapybullHypnosis
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Induction
bull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessment
bull Bishop Score- rating that determines if the cervix is ready for induction--Pg 765
bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole
-Inadequate uterine relaxation between contractions
lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveries
bull Forcepsbull Indications unable to push arrested descent need a
quick delivery breechbull Associated with maternalfetal birth trauma rectal
sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina
Cervix returns to firm nongravid consistency by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum
Assessment turn pt to side in Simrsquos position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy
Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments
Constipation Give stool softeners as ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis
Superficial leg vein diseasendash Ss tenderness in portion of vein local heat amp
redness normal temperature or low-grade feverndash Tx local heat elevate limb bed rest analgesia
elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation
Engorgement day 3 or 4ndash If breastfeeding
Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions
Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
bull Stop pitocinbull Reposition to left lateral Trendelenberg if neededbull Oxygen via mask at 8-10 Lminbull Increase IV fluidsbull SQ terbutaline (025 mg) if uterus not relaxingbull Vaginal exam for possible cause prolapse fetal
descent rupture abruptionbull Amnioinfusion for variable decelsbull Notify MDmidwife
Which strip shows signs thatImmediate intervention is needed Why What would you do
A
B
Experiences of Pain
bull Etiology bull Physiologybull Perception
bull Factors influencingAnxiety Psychological factorsExpectations Cultural factors
Support Fetal position
Comfort and Pain Relief
bull Support from doula or coachbull Alternative therapies
bullRelaxationmassagebull Focusing and imagerybullBreathingbullHerbal preparationsaromatherapybullHypnosis
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Induction
bull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessment
bull Bishop Score- rating that determines if the cervix is ready for induction--Pg 765
bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole
-Inadequate uterine relaxation between contractions
lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveries
bull Forcepsbull Indications unable to push arrested descent need a
quick delivery breechbull Associated with maternalfetal birth trauma rectal
sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina
Cervix returns to firm nongravid consistency by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum
Assessment turn pt to side in Simrsquos position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy
Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments
Constipation Give stool softeners as ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis
Superficial leg vein diseasendash Ss tenderness in portion of vein local heat amp
redness normal temperature or low-grade feverndash Tx local heat elevate limb bed rest analgesia
elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation
Engorgement day 3 or 4ndash If breastfeeding
Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions
Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
bull Stop pitocinbull Reposition to left lateral Trendelenberg if neededbull Oxygen via mask at 8-10 Lminbull Increase IV fluidsbull SQ terbutaline (025 mg) if uterus not relaxingbull Vaginal exam for possible cause prolapse fetal
descent rupture abruptionbull Amnioinfusion for variable decelsbull Notify MDmidwife
Which strip shows signs thatImmediate intervention is needed Why What would you do
A
B
Experiences of Pain
bull Etiology bull Physiologybull Perception
bull Factors influencingAnxiety Psychological factorsExpectations Cultural factors
Support Fetal position
Comfort and Pain Relief
bull Support from doula or coachbull Alternative therapies
bullRelaxationmassagebull Focusing and imagerybullBreathingbullHerbal preparationsaromatherapybullHypnosis
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Induction
bull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessment
bull Bishop Score- rating that determines if the cervix is ready for induction--Pg 765
bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole
-Inadequate uterine relaxation between contractions
lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveries
bull Forcepsbull Indications unable to push arrested descent need a
quick delivery breechbull Associated with maternalfetal birth trauma rectal
sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina
Cervix returns to firm nongravid consistency by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum
Assessment turn pt to side in Simrsquos position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy
Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments
Constipation Give stool softeners as ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis
Superficial leg vein diseasendash Ss tenderness in portion of vein local heat amp
redness normal temperature or low-grade feverndash Tx local heat elevate limb bed rest analgesia
elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation
Engorgement day 3 or 4ndash If breastfeeding
Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions
Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Chapter 22--Processes amp Stages of Labor and Birth
Critical Factors In Labor
Passenger
Slide 4
Slide 5
Fetal Lie and Presentation
Slide 7
Passenger (2)
Powers
Onset of labor
False vs True Labor Contractions
False vs True Labor Cervix
Critical Thinking
Stages of Labor First Stage
Slide 15
Slide 16
Slide 17
Dilatation amp Effacement
Care of Laboring Patient Early Labor
Care of Laboring Patient Active Labor
Stages of Labor Second Stage
Slide 22
Head Rotation during Descent
Slide 24
Stages of Labor Third Stage
Critical Thinking (2)
Chapter 23 Intrapartal Nursing Assessment
Initial Intrapartum Assessment Pages 608-612
Intrauterine Fetal Resuscitation
Slide 30
Experiences of Pain
Comfort and Pain Relief
Comfort and Pain Relief (2)
Systemic Analgesia Table 25-3 pg 690
Regional Anesthesia
Slide 36
Medication for Pain Relief Birth
Local anesthesia for Episiotomy
Childbirth at Risk (Ch 26)
Critical Thinking (3)
Precipitous Labor amp Birth
Postterm Pregnancy
Malpresentations
Malpresentations (cont)
External Version
MacrosomiaShoulder Dystocia
Slide 47
McRoberts Maneuvers Video
Multiple Gestation
Multiple Gestation (cont)
Abruptio Placentae
Slide 52
Abruptio Placentae (cont)
Placenta Previa
Slide 55
Prolapsed Cord
Prolapsed Cord (2)
Birth Related Procedures Chapter 27
Methods of Induction
Indications for induction of labor
Contraindications to Induction
Cervical Ripening Assessment
Oxytocin Induction pg 767
When to Discontinue Oxytocin
Operative Assisted Deliveries
Slide 66
Cesarean Birth Indications for
Cesarean Birth (cont)
Slide 69
Cesarean Birth
Post-Op Care
Critical Thinking (4)
POSTPARTUM CARE
Slide 74
Postpartum Psychological Adaptations Reva Rubin
Maternal Responses to Newborn Reva Rubin
Blues vs Dpression
Endocrine Adaptations
Physiological Adaptations
Slide 80
Fundal Assessment
Slide 82
Lochia
Lochia Assessment
Lochia Assessment (2)
Cervix amp Vagina
Perineum
Episiotomy
Other Assessments
Thrombophlebitis
Urinary Retention
Vital Signs
Breast Assessment
Lactation
Discharge Instructions
Postpartum Complications
Hemorrhage
Hemorrhage (cont)
Hematomas
Postpartum Infection
Postpartum Infection (2)
Endometritis
Postpartum Infection (3)
Slide 104
Slide 105
Slide 107
Slide 108
Slide 109
Slide 110
Breastfeeding
Intrauterine Fetal Resuscitation
bull Stop pitocinbull Reposition to left lateral Trendelenberg if neededbull Oxygen via mask at 8-10 Lminbull Increase IV fluidsbull SQ terbutaline (025 mg) if uterus not relaxingbull Vaginal exam for possible cause prolapse fetal
descent rupture abruptionbull Amnioinfusion for variable decelsbull Notify MDmidwife
Which strip shows signs thatImmediate intervention is needed Why What would you do
A
B
Experiences of Pain
bull Etiology bull Physiologybull Perception
bull Factors influencingAnxiety Psychological factorsExpectations Cultural factors
Support Fetal position
Comfort and Pain Relief
bull Support from doula or coachbull Alternative therapies
bullRelaxationmassagebull Focusing and imagerybullBreathingbullHerbal preparationsaromatherapybullHypnosis
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Induction
bull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessment
bull Bishop Score- rating that determines if the cervix is ready for induction--Pg 765
bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole
-Inadequate uterine relaxation between contractions
lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveries
bull Forcepsbull Indications unable to push arrested descent need a
quick delivery breechbull Associated with maternalfetal birth trauma rectal
sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina
Cervix returns to firm nongravid consistency by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum
Assessment turn pt to side in Simrsquos position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy
Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments
Constipation Give stool softeners as ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis
Superficial leg vein diseasendash Ss tenderness in portion of vein local heat amp
redness normal temperature or low-grade feverndash Tx local heat elevate limb bed rest analgesia
elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation
Engorgement day 3 or 4ndash If breastfeeding
Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions
Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Induction
bull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessment
bull Bishop Score- rating that determines if the cervix is ready for induction--Pg 765
bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole
-Inadequate uterine relaxation between contractions
lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveries
bull Forcepsbull Indications unable to push arrested descent need a
quick delivery breechbull Associated with maternalfetal birth trauma rectal
sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina
Cervix returns to firm nongravid consistency by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum
Assessment turn pt to side in Simrsquos position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy
Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments
Constipation Give stool softeners as ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis
Superficial leg vein diseasendash Ss tenderness in portion of vein local heat amp
redness normal temperature or low-grade feverndash Tx local heat elevate limb bed rest analgesia
elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation
Engorgement day 3 or 4ndash If breastfeeding
Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions
Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Induction
bull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessment
bull Bishop Score- rating that determines if the cervix is ready for induction--Pg 765
bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole
-Inadequate uterine relaxation between contractions
lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveries
bull Forcepsbull Indications unable to push arrested descent need a
quick delivery breechbull Associated with maternalfetal birth trauma rectal
sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina
Cervix returns to firm nongravid consistency by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum
Assessment turn pt to side in Simrsquos position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy
Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments
Constipation Give stool softeners as ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis
Superficial leg vein diseasendash Ss tenderness in portion of vein local heat amp
redness normal temperature or low-grade feverndash Tx local heat elevate limb bed rest analgesia
elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation
Engorgement day 3 or 4ndash If breastfeeding
Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions
Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Induction
bull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessment
bull Bishop Score- rating that determines if the cervix is ready for induction--Pg 765
bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole
-Inadequate uterine relaxation between contractions
lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveries
bull Forcepsbull Indications unable to push arrested descent need a
quick delivery breechbull Associated with maternalfetal birth trauma rectal
sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina
Cervix returns to firm nongravid consistency by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum
Assessment turn pt to side in Simrsquos position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy
Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments
Constipation Give stool softeners as ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis
Superficial leg vein diseasendash Ss tenderness in portion of vein local heat amp
redness normal temperature or low-grade feverndash Tx local heat elevate limb bed rest analgesia
elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation
Engorgement day 3 or 4ndash If breastfeeding
Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions
Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Induction
bull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessment
bull Bishop Score- rating that determines if the cervix is ready for induction--Pg 765
bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole
-Inadequate uterine relaxation between contractions
lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveries
bull Forcepsbull Indications unable to push arrested descent need a
quick delivery breechbull Associated with maternalfetal birth trauma rectal
sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina
Cervix returns to firm nongravid consistency by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum
Assessment turn pt to side in Simrsquos position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy
Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments
Constipation Give stool softeners as ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis
Superficial leg vein diseasendash Ss tenderness in portion of vein local heat amp
redness normal temperature or low-grade feverndash Tx local heat elevate limb bed rest analgesia
elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation
Engorgement day 3 or 4ndash If breastfeeding
Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions
Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Induction
bull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessment
bull Bishop Score- rating that determines if the cervix is ready for induction--Pg 765
bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole
-Inadequate uterine relaxation between contractions
lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveries
bull Forcepsbull Indications unable to push arrested descent need a
quick delivery breechbull Associated with maternalfetal birth trauma rectal
sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina
Cervix returns to firm nongravid consistency by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum
Assessment turn pt to side in Simrsquos position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy
Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments
Constipation Give stool softeners as ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis
Superficial leg vein diseasendash Ss tenderness in portion of vein local heat amp
redness normal temperature or low-grade feverndash Tx local heat elevate limb bed rest analgesia
elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation
Engorgement day 3 or 4ndash If breastfeeding
Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions
Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Induction
bull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessment
bull Bishop Score- rating that determines if the cervix is ready for induction--Pg 765
bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole
-Inadequate uterine relaxation between contractions
lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveries
bull Forcepsbull Indications unable to push arrested descent need a
quick delivery breechbull Associated with maternalfetal birth trauma rectal
sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina
Cervix returns to firm nongravid consistency by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum
Assessment turn pt to side in Simrsquos position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy
Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments
Constipation Give stool softeners as ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis
Superficial leg vein diseasendash Ss tenderness in portion of vein local heat amp
redness normal temperature or low-grade feverndash Tx local heat elevate limb bed rest analgesia
elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation
Engorgement day 3 or 4ndash If breastfeeding
Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions
Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Induction
bull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessment
bull Bishop Score- rating that determines if the cervix is ready for induction--Pg 765
bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole
-Inadequate uterine relaxation between contractions
lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveries
bull Forcepsbull Indications unable to push arrested descent need a
quick delivery breechbull Associated with maternalfetal birth trauma rectal
sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina
Cervix returns to firm nongravid consistency by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum
Assessment turn pt to side in Simrsquos position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy
Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments
Constipation Give stool softeners as ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis
Superficial leg vein diseasendash Ss tenderness in portion of vein local heat amp
redness normal temperature or low-grade feverndash Tx local heat elevate limb bed rest analgesia
elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation
Engorgement day 3 or 4ndash If breastfeeding
Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions
Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Induction
bull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessment
bull Bishop Score- rating that determines if the cervix is ready for induction--Pg 765
bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole
-Inadequate uterine relaxation between contractions
lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveries
bull Forcepsbull Indications unable to push arrested descent need a
quick delivery breechbull Associated with maternalfetal birth trauma rectal
sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina
Cervix returns to firm nongravid consistency by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum
Assessment turn pt to side in Simrsquos position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy
Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments
Constipation Give stool softeners as ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis
Superficial leg vein diseasendash Ss tenderness in portion of vein local heat amp
redness normal temperature or low-grade feverndash Tx local heat elevate limb bed rest analgesia
elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation
Engorgement day 3 or 4ndash If breastfeeding
Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions
Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Induction
bull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessment
bull Bishop Score- rating that determines if the cervix is ready for induction--Pg 765
bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole
-Inadequate uterine relaxation between contractions
lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveries
bull Forcepsbull Indications unable to push arrested descent need a
quick delivery breechbull Associated with maternalfetal birth trauma rectal
sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina
Cervix returns to firm nongravid consistency by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum
Assessment turn pt to side in Simrsquos position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy
Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments
Constipation Give stool softeners as ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis
Superficial leg vein diseasendash Ss tenderness in portion of vein local heat amp
redness normal temperature or low-grade feverndash Tx local heat elevate limb bed rest analgesia
elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation
Engorgement day 3 or 4ndash If breastfeeding
Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions
Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Induction
bull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessment
bull Bishop Score- rating that determines if the cervix is ready for induction--Pg 765
bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole
-Inadequate uterine relaxation between contractions
lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveries
bull Forcepsbull Indications unable to push arrested descent need a
quick delivery breechbull Associated with maternalfetal birth trauma rectal
sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina
Cervix returns to firm nongravid consistency by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum
Assessment turn pt to side in Simrsquos position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy
Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments
Constipation Give stool softeners as ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis
Superficial leg vein diseasendash Ss tenderness in portion of vein local heat amp
redness normal temperature or low-grade feverndash Tx local heat elevate limb bed rest analgesia
elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation
Engorgement day 3 or 4ndash If breastfeeding
Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions
Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Induction
bull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessment
bull Bishop Score- rating that determines if the cervix is ready for induction--Pg 765
bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole
-Inadequate uterine relaxation between contractions
lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveries
bull Forcepsbull Indications unable to push arrested descent need a
quick delivery breechbull Associated with maternalfetal birth trauma rectal
sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina
Cervix returns to firm nongravid consistency by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum
Assessment turn pt to side in Simrsquos position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy
Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments
Constipation Give stool softeners as ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis
Superficial leg vein diseasendash Ss tenderness in portion of vein local heat amp
redness normal temperature or low-grade feverndash Tx local heat elevate limb bed rest analgesia
elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation
Engorgement day 3 or 4ndash If breastfeeding
Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions
Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Induction
bull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessment
bull Bishop Score- rating that determines if the cervix is ready for induction--Pg 765
bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole
-Inadequate uterine relaxation between contractions
lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveries
bull Forcepsbull Indications unable to push arrested descent need a
quick delivery breechbull Associated with maternalfetal birth trauma rectal
sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina
Cervix returns to firm nongravid consistency by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum
Assessment turn pt to side in Simrsquos position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy
Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments
Constipation Give stool softeners as ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis
Superficial leg vein diseasendash Ss tenderness in portion of vein local heat amp
redness normal temperature or low-grade feverndash Tx local heat elevate limb bed rest analgesia
elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation
Engorgement day 3 or 4ndash If breastfeeding
Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions
Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Induction
bull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessment
bull Bishop Score- rating that determines if the cervix is ready for induction--Pg 765
bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole
-Inadequate uterine relaxation between contractions
lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveries
bull Forcepsbull Indications unable to push arrested descent need a
quick delivery breechbull Associated with maternalfetal birth trauma rectal
sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina
Cervix returns to firm nongravid consistency by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum
Assessment turn pt to side in Simrsquos position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy
Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments
Constipation Give stool softeners as ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis
Superficial leg vein diseasendash Ss tenderness in portion of vein local heat amp
redness normal temperature or low-grade feverndash Tx local heat elevate limb bed rest analgesia
elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation
Engorgement day 3 or 4ndash If breastfeeding
Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions
Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Induction
bull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessment
bull Bishop Score- rating that determines if the cervix is ready for induction--Pg 765
bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole
-Inadequate uterine relaxation between contractions
lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveries
bull Forcepsbull Indications unable to push arrested descent need a
quick delivery breechbull Associated with maternalfetal birth trauma rectal
sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina
Cervix returns to firm nongravid consistency by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum
Assessment turn pt to side in Simrsquos position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy
Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments
Constipation Give stool softeners as ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis
Superficial leg vein diseasendash Ss tenderness in portion of vein local heat amp
redness normal temperature or low-grade feverndash Tx local heat elevate limb bed rest analgesia
elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation
Engorgement day 3 or 4ndash If breastfeeding
Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions
Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Induction
bull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessment
bull Bishop Score- rating that determines if the cervix is ready for induction--Pg 765
bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole
-Inadequate uterine relaxation between contractions
lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveries
bull Forcepsbull Indications unable to push arrested descent need a
quick delivery breechbull Associated with maternalfetal birth trauma rectal
sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina
Cervix returns to firm nongravid consistency by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum
Assessment turn pt to side in Simrsquos position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy
Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments
Constipation Give stool softeners as ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis
Superficial leg vein diseasendash Ss tenderness in portion of vein local heat amp
redness normal temperature or low-grade feverndash Tx local heat elevate limb bed rest analgesia
elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation
Engorgement day 3 or 4ndash If breastfeeding
Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions
Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Induction
bull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessment
bull Bishop Score- rating that determines if the cervix is ready for induction--Pg 765
bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole
-Inadequate uterine relaxation between contractions
lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveries
bull Forcepsbull Indications unable to push arrested descent need a
quick delivery breechbull Associated with maternalfetal birth trauma rectal
sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina
Cervix returns to firm nongravid consistency by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum
Assessment turn pt to side in Simrsquos position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy
Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments
Constipation Give stool softeners as ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis
Superficial leg vein diseasendash Ss tenderness in portion of vein local heat amp
redness normal temperature or low-grade feverndash Tx local heat elevate limb bed rest analgesia
elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation
Engorgement day 3 or 4ndash If breastfeeding
Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions
Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Induction
bull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessment
bull Bishop Score- rating that determines if the cervix is ready for induction--Pg 765
bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole
-Inadequate uterine relaxation between contractions
lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveries
bull Forcepsbull Indications unable to push arrested descent need a
quick delivery breechbull Associated with maternalfetal birth trauma rectal
sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina
Cervix returns to firm nongravid consistency by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum
Assessment turn pt to side in Simrsquos position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy
Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments
Constipation Give stool softeners as ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis
Superficial leg vein diseasendash Ss tenderness in portion of vein local heat amp
redness normal temperature or low-grade feverndash Tx local heat elevate limb bed rest analgesia
elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation
Engorgement day 3 or 4ndash If breastfeeding
Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions
Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Induction
bull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessment
bull Bishop Score- rating that determines if the cervix is ready for induction--Pg 765
bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole
-Inadequate uterine relaxation between contractions
lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveries
bull Forcepsbull Indications unable to push arrested descent need a
quick delivery breechbull Associated with maternalfetal birth trauma rectal
sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina
Cervix returns to firm nongravid consistency by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum
Assessment turn pt to side in Simrsquos position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy
Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments
Constipation Give stool softeners as ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis
Superficial leg vein diseasendash Ss tenderness in portion of vein local heat amp
redness normal temperature or low-grade feverndash Tx local heat elevate limb bed rest analgesia
elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation
Engorgement day 3 or 4ndash If breastfeeding
Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions
Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Induction
bull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessment
bull Bishop Score- rating that determines if the cervix is ready for induction--Pg 765
bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole
-Inadequate uterine relaxation between contractions
lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveries
bull Forcepsbull Indications unable to push arrested descent need a
quick delivery breechbull Associated with maternalfetal birth trauma rectal
sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina
Cervix returns to firm nongravid consistency by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum
Assessment turn pt to side in Simrsquos position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy
Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments
Constipation Give stool softeners as ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis
Superficial leg vein diseasendash Ss tenderness in portion of vein local heat amp
redness normal temperature or low-grade feverndash Tx local heat elevate limb bed rest analgesia
elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation
Engorgement day 3 or 4ndash If breastfeeding
Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions
Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Induction
bull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessment
bull Bishop Score- rating that determines if the cervix is ready for induction--Pg 765
bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole
-Inadequate uterine relaxation between contractions
lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveries
bull Forcepsbull Indications unable to push arrested descent need a
quick delivery breechbull Associated with maternalfetal birth trauma rectal
sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina
Cervix returns to firm nongravid consistency by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum
Assessment turn pt to side in Simrsquos position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy
Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments
Constipation Give stool softeners as ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis
Superficial leg vein diseasendash Ss tenderness in portion of vein local heat amp
redness normal temperature or low-grade feverndash Tx local heat elevate limb bed rest analgesia
elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation
Engorgement day 3 or 4ndash If breastfeeding
Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions
Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Induction
bull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessment
bull Bishop Score- rating that determines if the cervix is ready for induction--Pg 765
bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole
-Inadequate uterine relaxation between contractions
lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveries
bull Forcepsbull Indications unable to push arrested descent need a
quick delivery breechbull Associated with maternalfetal birth trauma rectal
sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina
Cervix returns to firm nongravid consistency by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum
Assessment turn pt to side in Simrsquos position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy
Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments
Constipation Give stool softeners as ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis
Superficial leg vein diseasendash Ss tenderness in portion of vein local heat amp
redness normal temperature or low-grade feverndash Tx local heat elevate limb bed rest analgesia
elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation
Engorgement day 3 or 4ndash If breastfeeding
Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions
Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Induction
bull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessment
bull Bishop Score- rating that determines if the cervix is ready for induction--Pg 765
bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole
-Inadequate uterine relaxation between contractions
lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveries
bull Forcepsbull Indications unable to push arrested descent need a
quick delivery breechbull Associated with maternalfetal birth trauma rectal
sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina
Cervix returns to firm nongravid consistency by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum
Assessment turn pt to side in Simrsquos position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy
Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments
Constipation Give stool softeners as ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis
Superficial leg vein diseasendash Ss tenderness in portion of vein local heat amp
redness normal temperature or low-grade feverndash Tx local heat elevate limb bed rest analgesia
elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation
Engorgement day 3 or 4ndash If breastfeeding
Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions
Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Induction
bull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessment
bull Bishop Score- rating that determines if the cervix is ready for induction--Pg 765
bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole
-Inadequate uterine relaxation between contractions
lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveries
bull Forcepsbull Indications unable to push arrested descent need a
quick delivery breechbull Associated with maternalfetal birth trauma rectal
sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina
Cervix returns to firm nongravid consistency by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum
Assessment turn pt to side in Simrsquos position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy
Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments
Constipation Give stool softeners as ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis
Superficial leg vein diseasendash Ss tenderness in portion of vein local heat amp
redness normal temperature or low-grade feverndash Tx local heat elevate limb bed rest analgesia
elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation
Engorgement day 3 or 4ndash If breastfeeding
Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions
Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Chapter 22--Processes amp Stages of Labor and Birth
Critical Factors In Labor
Passenger
Slide 4
Slide 5
Fetal Lie and Presentation
Slide 7
Passenger (2)
Powers
Onset of labor
False vs True Labor Contractions
False vs True Labor Cervix
Critical Thinking
Stages of Labor First Stage
Slide 15
Slide 16
Slide 17
Dilatation amp Effacement
Care of Laboring Patient Early Labor
Care of Laboring Patient Active Labor
Stages of Labor Second Stage
Slide 22
Head Rotation during Descent
Slide 24
Stages of Labor Third Stage
Critical Thinking (2)
Chapter 23 Intrapartal Nursing Assessment
Initial Intrapartum Assessment Pages 608-612
Intrauterine Fetal Resuscitation
Slide 30
Experiences of Pain
Comfort and Pain Relief
Comfort and Pain Relief (2)
Systemic Analgesia Table 25-3 pg 690
Regional Anesthesia
Slide 36
Medication for Pain Relief Birth
Local anesthesia for Episiotomy
Childbirth at Risk (Ch 26)
Critical Thinking (3)
Precipitous Labor amp Birth
Postterm Pregnancy
Malpresentations
Malpresentations (cont)
External Version
MacrosomiaShoulder Dystocia
Slide 47
McRoberts Maneuvers Video
Multiple Gestation
Multiple Gestation (cont)
Abruptio Placentae
Slide 52
Abruptio Placentae (cont)
Placenta Previa
Slide 55
Prolapsed Cord
Prolapsed Cord (2)
Birth Related Procedures Chapter 27
Methods of Induction
Indications for induction of labor
Contraindications to Induction
Cervical Ripening Assessment
Oxytocin Induction pg 767
When to Discontinue Oxytocin
Operative Assisted Deliveries
Slide 66
Cesarean Birth Indications for
Cesarean Birth (cont)
Slide 69
Cesarean Birth
Post-Op Care
Critical Thinking (4)
POSTPARTUM CARE
Slide 74
Postpartum Psychological Adaptations Reva Rubin
Maternal Responses to Newborn Reva Rubin
Blues vs Dpression
Endocrine Adaptations
Physiological Adaptations
Slide 80
Fundal Assessment
Slide 82
Lochia
Lochia Assessment
Lochia Assessment (2)
Cervix amp Vagina
Perineum
Episiotomy
Other Assessments
Thrombophlebitis
Urinary Retention
Vital Signs
Breast Assessment
Lactation
Discharge Instructions
Postpartum Complications
Hemorrhage
Hemorrhage (cont)
Hematomas
Postpartum Infection
Postpartum Infection (2)
Endometritis
Postpartum Infection (3)
Slide 104
Slide 105
Slide 107
Slide 108
Slide 109
Slide 110
Breastfeeding
Placenta Previabull Low implantation of placenta (1 in 200)
bull abrupt painless bright red bleeding
bull Associated with uarrparity adv maternal age previous c-section or uterine curettage multiple gestation
bull Dx ultrasound May resolve as pregnancy progresses
bull Bleeding common around 30 wks Bedrest VS IV fluids type amp cross-match
observe for bleedingbull Emergency assess bleeding hx ucrsquoslabor bull NEVER do vaginal exam C-Section delivery possibly before 37 wks Steroids for mom Watch
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Induction
bull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessment
bull Bishop Score- rating that determines if the cervix is ready for induction--Pg 765
bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole
-Inadequate uterine relaxation between contractions
lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveries
bull Forcepsbull Indications unable to push arrested descent need a
quick delivery breechbull Associated with maternalfetal birth trauma rectal
sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina
Cervix returns to firm nongravid consistency by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum
Assessment turn pt to side in Simrsquos position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy
Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments
Constipation Give stool softeners as ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis
Superficial leg vein diseasendash Ss tenderness in portion of vein local heat amp
redness normal temperature or low-grade feverndash Tx local heat elevate limb bed rest analgesia
elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation
Engorgement day 3 or 4ndash If breastfeeding
Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions
Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Chapter 22--Processes amp Stages of Labor and Birth
Critical Factors In Labor
Passenger
Slide 4
Slide 5
Fetal Lie and Presentation
Slide 7
Passenger (2)
Powers
Onset of labor
False vs True Labor Contractions
False vs True Labor Cervix
Critical Thinking
Stages of Labor First Stage
Slide 15
Slide 16
Slide 17
Dilatation amp Effacement
Care of Laboring Patient Early Labor
Care of Laboring Patient Active Labor
Stages of Labor Second Stage
Slide 22
Head Rotation during Descent
Slide 24
Stages of Labor Third Stage
Critical Thinking (2)
Chapter 23 Intrapartal Nursing Assessment
Initial Intrapartum Assessment Pages 608-612
Intrauterine Fetal Resuscitation
Slide 30
Experiences of Pain
Comfort and Pain Relief
Comfort and Pain Relief (2)
Systemic Analgesia Table 25-3 pg 690
Regional Anesthesia
Slide 36
Medication for Pain Relief Birth
Local anesthesia for Episiotomy
Childbirth at Risk (Ch 26)
Critical Thinking (3)
Precipitous Labor amp Birth
Postterm Pregnancy
Malpresentations
Malpresentations (cont)
External Version
MacrosomiaShoulder Dystocia
Slide 47
McRoberts Maneuvers Video
Multiple Gestation
Multiple Gestation (cont)
Abruptio Placentae
Slide 52
Abruptio Placentae (cont)
Placenta Previa
Slide 55
Prolapsed Cord
Prolapsed Cord (2)
Birth Related Procedures Chapter 27
Methods of Induction
Indications for induction of labor
Contraindications to Induction
Cervical Ripening Assessment
Oxytocin Induction pg 767
When to Discontinue Oxytocin
Operative Assisted Deliveries
Slide 66
Cesarean Birth Indications for
Cesarean Birth (cont)
Slide 69
Cesarean Birth
Post-Op Care
Critical Thinking (4)
POSTPARTUM CARE
Slide 74
Postpartum Psychological Adaptations Reva Rubin
Maternal Responses to Newborn Reva Rubin
Blues vs Dpression
Endocrine Adaptations
Physiological Adaptations
Slide 80
Fundal Assessment
Slide 82
Lochia
Lochia Assessment
Lochia Assessment (2)
Cervix amp Vagina
Perineum
Episiotomy
Other Assessments
Thrombophlebitis
Urinary Retention
Vital Signs
Breast Assessment
Lactation
Discharge Instructions
Postpartum Complications
Hemorrhage
Hemorrhage (cont)
Hematomas
Postpartum Infection
Postpartum Infection (2)
Endometritis
Postpartum Infection (3)
Slide 104
Slide 105
Slide 107
Slide 108
Slide 109
Slide 110
Breastfeeding
Low-lying Marginal
Partial Complete
Placenta Previas
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Induction
bull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessment
bull Bishop Score- rating that determines if the cervix is ready for induction--Pg 765
bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole
-Inadequate uterine relaxation between contractions
lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveries
bull Forcepsbull Indications unable to push arrested descent need a
quick delivery breechbull Associated with maternalfetal birth trauma rectal
sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina
Cervix returns to firm nongravid consistency by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum
Assessment turn pt to side in Simrsquos position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy
Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments
Constipation Give stool softeners as ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis
Superficial leg vein diseasendash Ss tenderness in portion of vein local heat amp
redness normal temperature or low-grade feverndash Tx local heat elevate limb bed rest analgesia
elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation
Engorgement day 3 or 4ndash If breastfeeding
Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions
Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Chapter 22--Processes amp Stages of Labor and Birth
Critical Factors In Labor
Passenger
Slide 4
Slide 5
Fetal Lie and Presentation
Slide 7
Passenger (2)
Powers
Onset of labor
False vs True Labor Contractions
False vs True Labor Cervix
Critical Thinking
Stages of Labor First Stage
Slide 15
Slide 16
Slide 17
Dilatation amp Effacement
Care of Laboring Patient Early Labor
Care of Laboring Patient Active Labor
Stages of Labor Second Stage
Slide 22
Head Rotation during Descent
Slide 24
Stages of Labor Third Stage
Critical Thinking (2)
Chapter 23 Intrapartal Nursing Assessment
Initial Intrapartum Assessment Pages 608-612
Intrauterine Fetal Resuscitation
Slide 30
Experiences of Pain
Comfort and Pain Relief
Comfort and Pain Relief (2)
Systemic Analgesia Table 25-3 pg 690
Regional Anesthesia
Slide 36
Medication for Pain Relief Birth
Local anesthesia for Episiotomy
Childbirth at Risk (Ch 26)
Critical Thinking (3)
Precipitous Labor amp Birth
Postterm Pregnancy
Malpresentations
Malpresentations (cont)
External Version
MacrosomiaShoulder Dystocia
Slide 47
McRoberts Maneuvers Video
Multiple Gestation
Multiple Gestation (cont)
Abruptio Placentae
Slide 52
Abruptio Placentae (cont)
Placenta Previa
Slide 55
Prolapsed Cord
Prolapsed Cord (2)
Birth Related Procedures Chapter 27
Methods of Induction
Indications for induction of labor
Contraindications to Induction
Cervical Ripening Assessment
Oxytocin Induction pg 767
When to Discontinue Oxytocin
Operative Assisted Deliveries
Slide 66
Cesarean Birth Indications for
Cesarean Birth (cont)
Slide 69
Cesarean Birth
Post-Op Care
Critical Thinking (4)
POSTPARTUM CARE
Slide 74
Postpartum Psychological Adaptations Reva Rubin
Maternal Responses to Newborn Reva Rubin
Blues vs Dpression
Endocrine Adaptations
Physiological Adaptations
Slide 80
Fundal Assessment
Slide 82
Lochia
Lochia Assessment
Lochia Assessment (2)
Cervix amp Vagina
Perineum
Episiotomy
Other Assessments
Thrombophlebitis
Urinary Retention
Vital Signs
Breast Assessment
Lactation
Discharge Instructions
Postpartum Complications
Hemorrhage
Hemorrhage (cont)
Hematomas
Postpartum Infection
Postpartum Infection (2)
Endometritis
Postpartum Infection (3)
Slide 104
Slide 105
Slide 107
Slide 108
Slide 109
Slide 110
Breastfeeding
Prolapsed Cordbull Loop of umbilical cord slips down in front of the
presenting partbull SS deceleration of FHT bradycardia persistent
variable decels cord palpatedor seen in vagina
bull Associated withbull Premature rupture of membranesbull Transverse or breech presentationbull Multiple gestationbull Placenta previabull Hydramniosbull CPD (non-engagement of fetal head)
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Induction
bull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessment
bull Bishop Score- rating that determines if the cervix is ready for induction--Pg 765
bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole
-Inadequate uterine relaxation between contractions
lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveries
bull Forcepsbull Indications unable to push arrested descent need a
quick delivery breechbull Associated with maternalfetal birth trauma rectal
sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina
Cervix returns to firm nongravid consistency by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum
Assessment turn pt to side in Simrsquos position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy
Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments
Constipation Give stool softeners as ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis
Superficial leg vein diseasendash Ss tenderness in portion of vein local heat amp
redness normal temperature or low-grade feverndash Tx local heat elevate limb bed rest analgesia
elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation
Engorgement day 3 or 4ndash If breastfeeding
Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions
Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Chapter 22--Processes amp Stages of Labor and Birth
Critical Factors In Labor
Passenger
Slide 4
Slide 5
Fetal Lie and Presentation
Slide 7
Passenger (2)
Powers
Onset of labor
False vs True Labor Contractions
False vs True Labor Cervix
Critical Thinking
Stages of Labor First Stage
Slide 15
Slide 16
Slide 17
Dilatation amp Effacement
Care of Laboring Patient Early Labor
Care of Laboring Patient Active Labor
Stages of Labor Second Stage
Slide 22
Head Rotation during Descent
Slide 24
Stages of Labor Third Stage
Critical Thinking (2)
Chapter 23 Intrapartal Nursing Assessment
Initial Intrapartum Assessment Pages 608-612
Intrauterine Fetal Resuscitation
Slide 30
Experiences of Pain
Comfort and Pain Relief
Comfort and Pain Relief (2)
Systemic Analgesia Table 25-3 pg 690
Regional Anesthesia
Slide 36
Medication for Pain Relief Birth
Local anesthesia for Episiotomy
Childbirth at Risk (Ch 26)
Critical Thinking (3)
Precipitous Labor amp Birth
Postterm Pregnancy
Malpresentations
Malpresentations (cont)
External Version
MacrosomiaShoulder Dystocia
Slide 47
McRoberts Maneuvers Video
Multiple Gestation
Multiple Gestation (cont)
Abruptio Placentae
Slide 52
Abruptio Placentae (cont)
Placenta Previa
Slide 55
Prolapsed Cord
Prolapsed Cord (2)
Birth Related Procedures Chapter 27
Methods of Induction
Indications for induction of labor
Contraindications to Induction
Cervical Ripening Assessment
Oxytocin Induction pg 767
When to Discontinue Oxytocin
Operative Assisted Deliveries
Slide 66
Cesarean Birth Indications for
Cesarean Birth (cont)
Slide 69
Cesarean Birth
Post-Op Care
Critical Thinking (4)
POSTPARTUM CARE
Slide 74
Postpartum Psychological Adaptations Reva Rubin
Maternal Responses to Newborn Reva Rubin
Blues vs Dpression
Endocrine Adaptations
Physiological Adaptations
Slide 80
Fundal Assessment
Slide 82
Lochia
Lochia Assessment
Lochia Assessment (2)
Cervix amp Vagina
Perineum
Episiotomy
Other Assessments
Thrombophlebitis
Urinary Retention
Vital Signs
Breast Assessment
Lactation
Discharge Instructions
Postpartum Complications
Hemorrhage
Hemorrhage (cont)
Hematomas
Postpartum Infection
Postpartum Infection (2)
Endometritis
Postpartum Infection (3)
Slide 104
Slide 105
Slide 107
Slide 108
Slide 109
Slide 110
Breastfeeding
Prolapsed Cordbull Management Hold fetal head off cord
Trendelenburg or kneechest position immediate emergency c-section
bull Preventionbull Watch fetal heart tones after rupture of
membranes (SROM or AROM) Do VE if any sign of fetal distress
bull If head not engaged women with ruptured membranes should not ambulate
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Induction
bull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessment
bull Bishop Score- rating that determines if the cervix is ready for induction--Pg 765
bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole
-Inadequate uterine relaxation between contractions
lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveries
bull Forcepsbull Indications unable to push arrested descent need a
quick delivery breechbull Associated with maternalfetal birth trauma rectal
sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina
Cervix returns to firm nongravid consistency by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum
Assessment turn pt to side in Simrsquos position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy
Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments
Constipation Give stool softeners as ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis
Superficial leg vein diseasendash Ss tenderness in portion of vein local heat amp
redness normal temperature or low-grade feverndash Tx local heat elevate limb bed rest analgesia
elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation
Engorgement day 3 or 4ndash If breastfeeding
Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions
Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Chapter 22--Processes amp Stages of Labor and Birth
Critical Factors In Labor
Passenger
Slide 4
Slide 5
Fetal Lie and Presentation
Slide 7
Passenger (2)
Powers
Onset of labor
False vs True Labor Contractions
False vs True Labor Cervix
Critical Thinking
Stages of Labor First Stage
Slide 15
Slide 16
Slide 17
Dilatation amp Effacement
Care of Laboring Patient Early Labor
Care of Laboring Patient Active Labor
Stages of Labor Second Stage
Slide 22
Head Rotation during Descent
Slide 24
Stages of Labor Third Stage
Critical Thinking (2)
Chapter 23 Intrapartal Nursing Assessment
Initial Intrapartum Assessment Pages 608-612
Intrauterine Fetal Resuscitation
Slide 30
Experiences of Pain
Comfort and Pain Relief
Comfort and Pain Relief (2)
Systemic Analgesia Table 25-3 pg 690
Regional Anesthesia
Slide 36
Medication for Pain Relief Birth
Local anesthesia for Episiotomy
Childbirth at Risk (Ch 26)
Critical Thinking (3)
Precipitous Labor amp Birth
Postterm Pregnancy
Malpresentations
Malpresentations (cont)
External Version
MacrosomiaShoulder Dystocia
Slide 47
McRoberts Maneuvers Video
Multiple Gestation
Multiple Gestation (cont)
Abruptio Placentae
Slide 52
Abruptio Placentae (cont)
Placenta Previa
Slide 55
Prolapsed Cord
Prolapsed Cord (2)
Birth Related Procedures Chapter 27
Methods of Induction
Indications for induction of labor
Contraindications to Induction
Cervical Ripening Assessment
Oxytocin Induction pg 767
When to Discontinue Oxytocin
Operative Assisted Deliveries
Slide 66
Cesarean Birth Indications for
Cesarean Birth (cont)
Slide 69
Cesarean Birth
Post-Op Care
Critical Thinking (4)
POSTPARTUM CARE
Slide 74
Postpartum Psychological Adaptations Reva Rubin
Maternal Responses to Newborn Reva Rubin
Blues vs Dpression
Endocrine Adaptations
Physiological Adaptations
Slide 80
Fundal Assessment
Slide 82
Lochia
Lochia Assessment
Lochia Assessment (2)
Cervix amp Vagina
Perineum
Episiotomy
Other Assessments
Thrombophlebitis
Urinary Retention
Vital Signs
Breast Assessment
Lactation
Discharge Instructions
Postpartum Complications
Hemorrhage
Hemorrhage (cont)
Hematomas
Postpartum Infection
Postpartum Infection (2)
Endometritis
Postpartum Infection (3)
Slide 104
Slide 105
Slide 107
Slide 108
Slide 109
Slide 110
Breastfeeding
Birth Related ProceduresChapter 27
Induction of laborbull The deliberate initiation of uterine contractions by
chemical or mechanical means to stimulate labor and birth before spontaneous onset of labor
bull Primary agent of induction Pitocin by IVbull Pitocin is also used to augment labor
bull If cervix not ldquoriperdquo may need a preparatory stage of cervical ripening before pitocin can be started rarr Cervidil
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Induction
bull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessment
bull Bishop Score- rating that determines if the cervix is ready for induction--Pg 765
bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole
-Inadequate uterine relaxation between contractions
lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveries
bull Forcepsbull Indications unable to push arrested descent need a
quick delivery breechbull Associated with maternalfetal birth trauma rectal
sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina
Cervix returns to firm nongravid consistency by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum
Assessment turn pt to side in Simrsquos position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy
Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments
Constipation Give stool softeners as ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis
Superficial leg vein diseasendash Ss tenderness in portion of vein local heat amp
redness normal temperature or low-grade feverndash Tx local heat elevate limb bed rest analgesia
elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation
Engorgement day 3 or 4ndash If breastfeeding
Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions
Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Chapter 22--Processes amp Stages of Labor and Birth
Critical Factors In Labor
Passenger
Slide 4
Slide 5
Fetal Lie and Presentation
Slide 7
Passenger (2)
Powers
Onset of labor
False vs True Labor Contractions
False vs True Labor Cervix
Critical Thinking
Stages of Labor First Stage
Slide 15
Slide 16
Slide 17
Dilatation amp Effacement
Care of Laboring Patient Early Labor
Care of Laboring Patient Active Labor
Stages of Labor Second Stage
Slide 22
Head Rotation during Descent
Slide 24
Stages of Labor Third Stage
Critical Thinking (2)
Chapter 23 Intrapartal Nursing Assessment
Initial Intrapartum Assessment Pages 608-612
Intrauterine Fetal Resuscitation
Slide 30
Experiences of Pain
Comfort and Pain Relief
Comfort and Pain Relief (2)
Systemic Analgesia Table 25-3 pg 690
Regional Anesthesia
Slide 36
Medication for Pain Relief Birth
Local anesthesia for Episiotomy
Childbirth at Risk (Ch 26)
Critical Thinking (3)
Precipitous Labor amp Birth
Postterm Pregnancy
Malpresentations
Malpresentations (cont)
External Version
MacrosomiaShoulder Dystocia
Slide 47
McRoberts Maneuvers Video
Multiple Gestation
Multiple Gestation (cont)
Abruptio Placentae
Slide 52
Abruptio Placentae (cont)
Placenta Previa
Slide 55
Prolapsed Cord
Prolapsed Cord (2)
Birth Related Procedures Chapter 27
Methods of Induction
Indications for induction of labor
Contraindications to Induction
Cervical Ripening Assessment
Oxytocin Induction pg 767
When to Discontinue Oxytocin
Operative Assisted Deliveries
Slide 66
Cesarean Birth Indications for
Cesarean Birth (cont)
Slide 69
Cesarean Birth
Post-Op Care
Critical Thinking (4)
POSTPARTUM CARE
Slide 74
Postpartum Psychological Adaptations Reva Rubin
Maternal Responses to Newborn Reva Rubin
Blues vs Dpression
Endocrine Adaptations
Physiological Adaptations
Slide 80
Fundal Assessment
Slide 82
Lochia
Lochia Assessment
Lochia Assessment (2)
Cervix amp Vagina
Perineum
Episiotomy
Other Assessments
Thrombophlebitis
Urinary Retention
Vital Signs
Breast Assessment
Lactation
Discharge Instructions
Postpartum Complications
Hemorrhage
Hemorrhage (cont)
Hematomas
Postpartum Infection
Postpartum Infection (2)
Endometritis
Postpartum Infection (3)
Slide 104
Slide 105
Slide 107
Slide 108
Slide 109
Slide 110
Breastfeeding
Methods of Inductionbull Prostaglandins (Cervidil prostin gel Prepidil
Cytotec) applied intravaginally for cervical ripening
bull Pitocin (oxytocin) by IVbull Amniotomy or stripping of membranesbull Sexual intercoursebull Nipple stimulationbull Herbal preparations
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Induction
bull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessment
bull Bishop Score- rating that determines if the cervix is ready for induction--Pg 765
bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole
-Inadequate uterine relaxation between contractions
lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveries
bull Forcepsbull Indications unable to push arrested descent need a
quick delivery breechbull Associated with maternalfetal birth trauma rectal
sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina
Cervix returns to firm nongravid consistency by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum
Assessment turn pt to side in Simrsquos position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy
Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments
Constipation Give stool softeners as ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis
Superficial leg vein diseasendash Ss tenderness in portion of vein local heat amp
redness normal temperature or low-grade feverndash Tx local heat elevate limb bed rest analgesia
elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation
Engorgement day 3 or 4ndash If breastfeeding
Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions
Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Chapter 22--Processes amp Stages of Labor and Birth
Critical Factors In Labor
Passenger
Slide 4
Slide 5
Fetal Lie and Presentation
Slide 7
Passenger (2)
Powers
Onset of labor
False vs True Labor Contractions
False vs True Labor Cervix
Critical Thinking
Stages of Labor First Stage
Slide 15
Slide 16
Slide 17
Dilatation amp Effacement
Care of Laboring Patient Early Labor
Care of Laboring Patient Active Labor
Stages of Labor Second Stage
Slide 22
Head Rotation during Descent
Slide 24
Stages of Labor Third Stage
Critical Thinking (2)
Chapter 23 Intrapartal Nursing Assessment
Initial Intrapartum Assessment Pages 608-612
Intrauterine Fetal Resuscitation
Slide 30
Experiences of Pain
Comfort and Pain Relief
Comfort and Pain Relief (2)
Systemic Analgesia Table 25-3 pg 690
Regional Anesthesia
Slide 36
Medication for Pain Relief Birth
Local anesthesia for Episiotomy
Childbirth at Risk (Ch 26)
Critical Thinking (3)
Precipitous Labor amp Birth
Postterm Pregnancy
Malpresentations
Malpresentations (cont)
External Version
MacrosomiaShoulder Dystocia
Slide 47
McRoberts Maneuvers Video
Multiple Gestation
Multiple Gestation (cont)
Abruptio Placentae
Slide 52
Abruptio Placentae (cont)
Placenta Previa
Slide 55
Prolapsed Cord
Prolapsed Cord (2)
Birth Related Procedures Chapter 27
Methods of Induction
Indications for induction of labor
Contraindications to Induction
Cervical Ripening Assessment
Oxytocin Induction pg 767
When to Discontinue Oxytocin
Operative Assisted Deliveries
Slide 66
Cesarean Birth Indications for
Cesarean Birth (cont)
Slide 69
Cesarean Birth
Post-Op Care
Critical Thinking (4)
POSTPARTUM CARE
Slide 74
Postpartum Psychological Adaptations Reva Rubin
Maternal Responses to Newborn Reva Rubin
Blues vs Dpression
Endocrine Adaptations
Physiological Adaptations
Slide 80
Fundal Assessment
Slide 82
Lochia
Lochia Assessment
Lochia Assessment (2)
Cervix amp Vagina
Perineum
Episiotomy
Other Assessments
Thrombophlebitis
Urinary Retention
Vital Signs
Breast Assessment
Lactation
Discharge Instructions
Postpartum Complications
Hemorrhage
Hemorrhage (cont)
Hematomas
Postpartum Infection
Postpartum Infection (2)
Endometritis
Postpartum Infection (3)
Slide 104
Slide 105
Slide 107
Slide 108
Slide 109
Slide 110
Breastfeeding
Indications for induction of laborbull Post-term pregnancy (ge 42 weeks)bull Premature or prolonged rupture of membranesbull Maternal complications (Rh isoimmunization
restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
bull Fetal demise
Contraindications to Induction
bull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessment
bull Bishop Score- rating that determines if the cervix is ready for induction--Pg 765
bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole
-Inadequate uterine relaxation between contractions
lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveries
bull Forcepsbull Indications unable to push arrested descent need a
quick delivery breechbull Associated with maternalfetal birth trauma rectal
sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina
Cervix returns to firm nongravid consistency by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum
Assessment turn pt to side in Simrsquos position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy
Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments
Constipation Give stool softeners as ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis
Superficial leg vein diseasendash Ss tenderness in portion of vein local heat amp
redness normal temperature or low-grade feverndash Tx local heat elevate limb bed rest analgesia
elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation
Engorgement day 3 or 4ndash If breastfeeding
Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions
Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Chapter 22--Processes amp Stages of Labor and Birth
Critical Factors In Labor
Passenger
Slide 4
Slide 5
Fetal Lie and Presentation
Slide 7
Passenger (2)
Powers
Onset of labor
False vs True Labor Contractions
False vs True Labor Cervix
Critical Thinking
Stages of Labor First Stage
Slide 15
Slide 16
Slide 17
Dilatation amp Effacement
Care of Laboring Patient Early Labor
Care of Laboring Patient Active Labor
Stages of Labor Second Stage
Slide 22
Head Rotation during Descent
Slide 24
Stages of Labor Third Stage
Critical Thinking (2)
Chapter 23 Intrapartal Nursing Assessment
Initial Intrapartum Assessment Pages 608-612
Intrauterine Fetal Resuscitation
Slide 30
Experiences of Pain
Comfort and Pain Relief
Comfort and Pain Relief (2)
Systemic Analgesia Table 25-3 pg 690
Regional Anesthesia
Slide 36
Medication for Pain Relief Birth
Local anesthesia for Episiotomy
Childbirth at Risk (Ch 26)
Critical Thinking (3)
Precipitous Labor amp Birth
Postterm Pregnancy
Malpresentations
Malpresentations (cont)
External Version
MacrosomiaShoulder Dystocia
Slide 47
McRoberts Maneuvers Video
Multiple Gestation
Multiple Gestation (cont)
Abruptio Placentae
Slide 52
Abruptio Placentae (cont)
Placenta Previa
Slide 55
Prolapsed Cord
Prolapsed Cord (2)
Birth Related Procedures Chapter 27
Methods of Induction
Indications for induction of labor
Contraindications to Induction
Cervical Ripening Assessment
Oxytocin Induction pg 767
When to Discontinue Oxytocin
Operative Assisted Deliveries
Slide 66
Cesarean Birth Indications for
Cesarean Birth (cont)
Slide 69
Cesarean Birth
Post-Op Care
Critical Thinking (4)
POSTPARTUM CARE
Slide 74
Postpartum Psychological Adaptations Reva Rubin
Maternal Responses to Newborn Reva Rubin
Blues vs Dpression
Endocrine Adaptations
Physiological Adaptations
Slide 80
Fundal Assessment
Slide 82
Lochia
Lochia Assessment
Lochia Assessment (2)
Cervix amp Vagina
Perineum
Episiotomy
Other Assessments
Thrombophlebitis
Urinary Retention
Vital Signs
Breast Assessment
Lactation
Discharge Instructions
Postpartum Complications
Hemorrhage
Hemorrhage (cont)
Hematomas
Postpartum Infection
Postpartum Infection (2)
Endometritis
Postpartum Infection (3)
Slide 104
Slide 105
Slide 107
Slide 108
Slide 109
Slide 110
Breastfeeding
Contraindications to Induction
bull previous c-section bull placenta previa or abruption bull prolapsed cordbull fetal bradycardia nonreassuring fetal statusbull vaginal bleeding of unknown causebull cephalopelvic disproportionbull active genital herpes
Cervical Ripening Assessment
bull Bishop Score- rating that determines if the cervix is ready for induction--Pg 765
bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole
-Inadequate uterine relaxation between contractions
lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveries
bull Forcepsbull Indications unable to push arrested descent need a
quick delivery breechbull Associated with maternalfetal birth trauma rectal
sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina
Cervix returns to firm nongravid consistency by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum
Assessment turn pt to side in Simrsquos position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy
Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments
Constipation Give stool softeners as ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis
Superficial leg vein diseasendash Ss tenderness in portion of vein local heat amp
redness normal temperature or low-grade feverndash Tx local heat elevate limb bed rest analgesia
elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation
Engorgement day 3 or 4ndash If breastfeeding
Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions
Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Chapter 22--Processes amp Stages of Labor and Birth
Critical Factors In Labor
Passenger
Slide 4
Slide 5
Fetal Lie and Presentation
Slide 7
Passenger (2)
Powers
Onset of labor
False vs True Labor Contractions
False vs True Labor Cervix
Critical Thinking
Stages of Labor First Stage
Slide 15
Slide 16
Slide 17
Dilatation amp Effacement
Care of Laboring Patient Early Labor
Care of Laboring Patient Active Labor
Stages of Labor Second Stage
Slide 22
Head Rotation during Descent
Slide 24
Stages of Labor Third Stage
Critical Thinking (2)
Chapter 23 Intrapartal Nursing Assessment
Initial Intrapartum Assessment Pages 608-612
Intrauterine Fetal Resuscitation
Slide 30
Experiences of Pain
Comfort and Pain Relief
Comfort and Pain Relief (2)
Systemic Analgesia Table 25-3 pg 690
Regional Anesthesia
Slide 36
Medication for Pain Relief Birth
Local anesthesia for Episiotomy
Childbirth at Risk (Ch 26)
Critical Thinking (3)
Precipitous Labor amp Birth
Postterm Pregnancy
Malpresentations
Malpresentations (cont)
External Version
MacrosomiaShoulder Dystocia
Slide 47
McRoberts Maneuvers Video
Multiple Gestation
Multiple Gestation (cont)
Abruptio Placentae
Slide 52
Abruptio Placentae (cont)
Placenta Previa
Slide 55
Prolapsed Cord
Prolapsed Cord (2)
Birth Related Procedures Chapter 27
Methods of Induction
Indications for induction of labor
Contraindications to Induction
Cervical Ripening Assessment
Oxytocin Induction pg 767
When to Discontinue Oxytocin
Operative Assisted Deliveries
Slide 66
Cesarean Birth Indications for
Cesarean Birth (cont)
Slide 69
Cesarean Birth
Post-Op Care
Critical Thinking (4)
POSTPARTUM CARE
Slide 74
Postpartum Psychological Adaptations Reva Rubin
Maternal Responses to Newborn Reva Rubin
Blues vs Dpression
Endocrine Adaptations
Physiological Adaptations
Slide 80
Fundal Assessment
Slide 82
Lochia
Lochia Assessment
Lochia Assessment (2)
Cervix amp Vagina
Perineum
Episiotomy
Other Assessments
Thrombophlebitis
Urinary Retention
Vital Signs
Breast Assessment
Lactation
Discharge Instructions
Postpartum Complications
Hemorrhage
Hemorrhage (cont)
Hematomas
Postpartum Infection
Postpartum Infection (2)
Endometritis
Postpartum Infection (3)
Slide 104
Slide 105
Slide 107
Slide 108
Slide 109
Slide 110
Breastfeeding
Cervical Ripening Assessment
bull Bishop Score- rating that determines if the cervix is ready for induction--Pg 765
bull Fetus must be in vertex positionbull Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)bull Fetal monitoring and uterine contraction
monitoring is imperativebull Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole
-Inadequate uterine relaxation between contractions
lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveries
bull Forcepsbull Indications unable to push arrested descent need a
quick delivery breechbull Associated with maternalfetal birth trauma rectal
sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina
Cervix returns to firm nongravid consistency by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum
Assessment turn pt to side in Simrsquos position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy
Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments
Constipation Give stool softeners as ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis
Superficial leg vein diseasendash Ss tenderness in portion of vein local heat amp
redness normal temperature or low-grade feverndash Tx local heat elevate limb bed rest analgesia
elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation
Engorgement day 3 or 4ndash If breastfeeding
Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions
Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Chapter 22--Processes amp Stages of Labor and Birth
Critical Factors In Labor
Passenger
Slide 4
Slide 5
Fetal Lie and Presentation
Slide 7
Passenger (2)
Powers
Onset of labor
False vs True Labor Contractions
False vs True Labor Cervix
Critical Thinking
Stages of Labor First Stage
Slide 15
Slide 16
Slide 17
Dilatation amp Effacement
Care of Laboring Patient Early Labor
Care of Laboring Patient Active Labor
Stages of Labor Second Stage
Slide 22
Head Rotation during Descent
Slide 24
Stages of Labor Third Stage
Critical Thinking (2)
Chapter 23 Intrapartal Nursing Assessment
Initial Intrapartum Assessment Pages 608-612
Intrauterine Fetal Resuscitation
Slide 30
Experiences of Pain
Comfort and Pain Relief
Comfort and Pain Relief (2)
Systemic Analgesia Table 25-3 pg 690
Regional Anesthesia
Slide 36
Medication for Pain Relief Birth
Local anesthesia for Episiotomy
Childbirth at Risk (Ch 26)
Critical Thinking (3)
Precipitous Labor amp Birth
Postterm Pregnancy
Malpresentations
Malpresentations (cont)
External Version
MacrosomiaShoulder Dystocia
Slide 47
McRoberts Maneuvers Video
Multiple Gestation
Multiple Gestation (cont)
Abruptio Placentae
Slide 52
Abruptio Placentae (cont)
Placenta Previa
Slide 55
Prolapsed Cord
Prolapsed Cord (2)
Birth Related Procedures Chapter 27
Methods of Induction
Indications for induction of labor
Contraindications to Induction
Cervical Ripening Assessment
Oxytocin Induction pg 767
When to Discontinue Oxytocin
Operative Assisted Deliveries
Slide 66
Cesarean Birth Indications for
Cesarean Birth (cont)
Slide 69
Cesarean Birth
Post-Op Care
Critical Thinking (4)
POSTPARTUM CARE
Slide 74
Postpartum Psychological Adaptations Reva Rubin
Maternal Responses to Newborn Reva Rubin
Blues vs Dpression
Endocrine Adaptations
Physiological Adaptations
Slide 80
Fundal Assessment
Slide 82
Lochia
Lochia Assessment
Lochia Assessment (2)
Cervix amp Vagina
Perineum
Episiotomy
Other Assessments
Thrombophlebitis
Urinary Retention
Vital Signs
Breast Assessment
Lactation
Discharge Instructions
Postpartum Complications
Hemorrhage
Hemorrhage (cont)
Hematomas
Postpartum Infection
Postpartum Infection (2)
Endometritis
Postpartum Infection (3)
Slide 104
Slide 105
Slide 107
Slide 108
Slide 109
Slide 110
Breastfeeding
Oxytocin Inductionpg 767
bull Confirmation that the baby is in a cephalic (vertex) position (head down)
bull VS done at least every 30 minutes and when dose is titrated
bull FHTs and UCs assessed every 30 minutesbull Titration of oxytocin till UCs every 2-3 minutesbull Cervical dilation should be 2 cmhr (ideally)bull Reassuring FHTs between 110-160 beatsmin
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole
-Inadequate uterine relaxation between contractions
lt60 sec between UCrsquos
Fetal Distress -any decelerations or decreased baseline variability
Operative Assisted Deliveries
bull Forcepsbull Indications unable to push arrested descent need a
quick delivery breechbull Associated with maternalfetal birth trauma rectal
sphincter tear urinary stress incontinence
bull Vacuum extractionbull Advantages fewer lacerations less anesthesia neededbull Disadvantages marked caput cephalhematomas scalp
lacerationbruising
Cesarean BirthIndications for
Maternal Factorsbull Active genital herpesbull AIDSHIV +bull Cephalopelvic disproportionbull Severe preeclampsia diabetesbull Obstructive tumorbull Ruptured uterusbull Previous c-sectionbull Failed inductionfx to progress in
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina
Cervix returns to firm nongravid consistency by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum
Assessment turn pt to side in Simrsquos position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy
Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments
Constipation Give stool softeners as ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis
Superficial leg vein diseasendash Ss tenderness in portion of vein local heat amp
redness normal temperature or low-grade feverndash Tx local heat elevate limb bed rest analgesia
elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation
Engorgement day 3 or 4ndash If breastfeeding
Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions
Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina
Cervix returns to firm nongravid consistency by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum
Assessment turn pt to side in Simrsquos position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy
Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments
Constipation Give stool softeners as ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis
Superficial leg vein diseasendash Ss tenderness in portion of vein local heat amp
redness normal temperature or low-grade feverndash Tx local heat elevate limb bed rest analgesia
elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation
Engorgement day 3 or 4ndash If breastfeeding
Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions
Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina
Cervix returns to firm nongravid consistency by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum
Assessment turn pt to side in Simrsquos position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy
Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments
Constipation Give stool softeners as ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis
Superficial leg vein diseasendash Ss tenderness in portion of vein local heat amp
redness normal temperature or low-grade feverndash Tx local heat elevate limb bed rest analgesia
elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation
Engorgement day 3 or 4ndash If breastfeeding
Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions
Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina
Cervix returns to firm nongravid consistency by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum
Assessment turn pt to side in Simrsquos position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy
Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments
Constipation Give stool softeners as ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis
Superficial leg vein diseasendash Ss tenderness in portion of vein local heat amp
redness normal temperature or low-grade feverndash Tx local heat elevate limb bed rest analgesia
elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation
Engorgement day 3 or 4ndash If breastfeeding
Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions
Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina
Cervix returns to firm nongravid consistency by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum
Assessment turn pt to side in Simrsquos position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy
Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments
Constipation Give stool softeners as ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis
Superficial leg vein diseasendash Ss tenderness in portion of vein local heat amp
redness normal temperature or low-grade feverndash Tx local heat elevate limb bed rest analgesia
elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation
Engorgement day 3 or 4ndash If breastfeeding
Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions
Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina
Cervix returns to firm nongravid consistency by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum
Assessment turn pt to side in Simrsquos position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy
Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments
Constipation Give stool softeners as ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis
Superficial leg vein diseasendash Ss tenderness in portion of vein local heat amp
redness normal temperature or low-grade feverndash Tx local heat elevate limb bed rest analgesia
elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation
Engorgement day 3 or 4ndash If breastfeeding
Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions
Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina
Cervix returns to firm nongravid consistency by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum
Assessment turn pt to side in Simrsquos position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy
Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments
Constipation Give stool softeners as ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis
Superficial leg vein diseasendash Ss tenderness in portion of vein local heat amp
redness normal temperature or low-grade feverndash Tx local heat elevate limb bed rest analgesia
elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation
Engorgement day 3 or 4ndash If breastfeeding
Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions
Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Chapter 22--Processes amp Stages of Labor and Birth
Critical Factors In Labor
Passenger
Slide 4
Slide 5
Fetal Lie and Presentation
Slide 7
Passenger (2)
Powers
Onset of labor
False vs True Labor Contractions
False vs True Labor Cervix
Critical Thinking
Stages of Labor First Stage
Slide 15
Slide 16
Slide 17
Dilatation amp Effacement
Care of Laboring Patient Early Labor
Care of Laboring Patient Active Labor
Stages of Labor Second Stage
Slide 22
Head Rotation during Descent
Slide 24
Stages of Labor Third Stage
Critical Thinking (2)
Chapter 23 Intrapartal Nursing Assessment
Initial Intrapartum Assessment Pages 608-612
Intrauterine Fetal Resuscitation
Slide 30
Experiences of Pain
Comfort and Pain Relief
Comfort and Pain Relief (2)
Systemic Analgesia Table 25-3 pg 690
Regional Anesthesia
Slide 36
Medication for Pain Relief Birth
Local anesthesia for Episiotomy
Childbirth at Risk (Ch 26)
Critical Thinking (3)
Precipitous Labor amp Birth
Postterm Pregnancy
Malpresentations
Malpresentations (cont)
External Version
MacrosomiaShoulder Dystocia
Slide 47
McRoberts Maneuvers Video
Multiple Gestation
Multiple Gestation (cont)
Abruptio Placentae
Slide 52
Abruptio Placentae (cont)
Placenta Previa
Slide 55
Prolapsed Cord
Prolapsed Cord (2)
Birth Related Procedures Chapter 27
Methods of Induction
Indications for induction of labor
Contraindications to Induction
Cervical Ripening Assessment
Oxytocin Induction pg 767
When to Discontinue Oxytocin
Operative Assisted Deliveries
Slide 66
Cesarean Birth Indications for
Cesarean Birth (cont)
Slide 69
Cesarean Birth
Post-Op Care
Critical Thinking (4)
POSTPARTUM CARE
Slide 74
Postpartum Psychological Adaptations Reva Rubin
Maternal Responses to Newborn Reva Rubin
Blues vs Dpression
Endocrine Adaptations
Physiological Adaptations
Slide 80
Fundal Assessment
Slide 82
Lochia
Lochia Assessment
Lochia Assessment (2)
Cervix amp Vagina
Perineum
Episiotomy
Other Assessments
Thrombophlebitis
Urinary Retention
Vital Signs
Breast Assessment
Lactation
Discharge Instructions
Postpartum Complications
Hemorrhage
Hemorrhage (cont)
Hematomas
Postpartum Infection
Postpartum Infection (2)
Endometritis
Postpartum Infection (3)
Slide 104
Slide 105
Slide 107
Slide 108
Slide 109
Slide 110
Breastfeeding
Critical Thinkingbull A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation between contractions Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first
A) Notify the physician of these findings B) Place the woman in knee-chest position C) Turn off the lights to make it easier for the woman to
relax D) Assemble supplies to prepare for birth
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina
Cervix returns to firm nongravid consistency by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum
Assessment turn pt to side in Simrsquos position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy
Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments
Constipation Give stool softeners as ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis
Superficial leg vein diseasendash Ss tenderness in portion of vein local heat amp
redness normal temperature or low-grade feverndash Tx local heat elevate limb bed rest analgesia
elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation
Engorgement day 3 or 4ndash If breastfeeding
Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions
Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Chapter 22--Processes amp Stages of Labor and Birth
Critical Factors In Labor
Passenger
Slide 4
Slide 5
Fetal Lie and Presentation
Slide 7
Passenger (2)
Powers
Onset of labor
False vs True Labor Contractions
False vs True Labor Cervix
Critical Thinking
Stages of Labor First Stage
Slide 15
Slide 16
Slide 17
Dilatation amp Effacement
Care of Laboring Patient Early Labor
Care of Laboring Patient Active Labor
Stages of Labor Second Stage
Slide 22
Head Rotation during Descent
Slide 24
Stages of Labor Third Stage
Critical Thinking (2)
Chapter 23 Intrapartal Nursing Assessment
Initial Intrapartum Assessment Pages 608-612
Intrauterine Fetal Resuscitation
Slide 30
Experiences of Pain
Comfort and Pain Relief
Comfort and Pain Relief (2)
Systemic Analgesia Table 25-3 pg 690
Regional Anesthesia
Slide 36
Medication for Pain Relief Birth
Local anesthesia for Episiotomy
Childbirth at Risk (Ch 26)
Critical Thinking (3)
Precipitous Labor amp Birth
Postterm Pregnancy
Malpresentations
Malpresentations (cont)
External Version
MacrosomiaShoulder Dystocia
Slide 47
McRoberts Maneuvers Video
Multiple Gestation
Multiple Gestation (cont)
Abruptio Placentae
Slide 52
Abruptio Placentae (cont)
Placenta Previa
Slide 55
Prolapsed Cord
Prolapsed Cord (2)
Birth Related Procedures Chapter 27
Methods of Induction
Indications for induction of labor
Contraindications to Induction
Cervical Ripening Assessment
Oxytocin Induction pg 767
When to Discontinue Oxytocin
Operative Assisted Deliveries
Slide 66
Cesarean Birth Indications for
Cesarean Birth (cont)
Slide 69
Cesarean Birth
Post-Op Care
Critical Thinking (4)
POSTPARTUM CARE
Slide 74
Postpartum Psychological Adaptations Reva Rubin
Maternal Responses to Newborn Reva Rubin
Blues vs Dpression
Endocrine Adaptations
Physiological Adaptations
Slide 80
Fundal Assessment
Slide 82
Lochia
Lochia Assessment
Lochia Assessment (2)
Cervix amp Vagina
Perineum
Episiotomy
Other Assessments
Thrombophlebitis
Urinary Retention
Vital Signs
Breast Assessment
Lactation
Discharge Instructions
Postpartum Complications
Hemorrhage
Hemorrhage (cont)
Hematomas
Postpartum Infection
Postpartum Infection (2)
Endometritis
Postpartum Infection (3)
Slide 104
Slide 105
Slide 107
Slide 108
Slide 109
Slide 110
Breastfeeding
POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina
Cervix returns to firm nongravid consistency by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum
Assessment turn pt to side in Simrsquos position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy
Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments
Constipation Give stool softeners as ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis
Superficial leg vein diseasendash Ss tenderness in portion of vein local heat amp
redness normal temperature or low-grade feverndash Tx local heat elevate limb bed rest analgesia
elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation
Engorgement day 3 or 4ndash If breastfeeding
Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions
Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Chapter 22--Processes amp Stages of Labor and Birth
Critical Factors In Labor
Passenger
Slide 4
Slide 5
Fetal Lie and Presentation
Slide 7
Passenger (2)
Powers
Onset of labor
False vs True Labor Contractions
False vs True Labor Cervix
Critical Thinking
Stages of Labor First Stage
Slide 15
Slide 16
Slide 17
Dilatation amp Effacement
Care of Laboring Patient Early Labor
Care of Laboring Patient Active Labor
Stages of Labor Second Stage
Slide 22
Head Rotation during Descent
Slide 24
Stages of Labor Third Stage
Critical Thinking (2)
Chapter 23 Intrapartal Nursing Assessment
Initial Intrapartum Assessment Pages 608-612
Intrauterine Fetal Resuscitation
Slide 30
Experiences of Pain
Comfort and Pain Relief
Comfort and Pain Relief (2)
Systemic Analgesia Table 25-3 pg 690
Regional Anesthesia
Slide 36
Medication for Pain Relief Birth
Local anesthesia for Episiotomy
Childbirth at Risk (Ch 26)
Critical Thinking (3)
Precipitous Labor amp Birth
Postterm Pregnancy
Malpresentations
Malpresentations (cont)
External Version
MacrosomiaShoulder Dystocia
Slide 47
McRoberts Maneuvers Video
Multiple Gestation
Multiple Gestation (cont)
Abruptio Placentae
Slide 52
Abruptio Placentae (cont)
Placenta Previa
Slide 55
Prolapsed Cord
Prolapsed Cord (2)
Birth Related Procedures Chapter 27
Methods of Induction
Indications for induction of labor
Contraindications to Induction
Cervical Ripening Assessment
Oxytocin Induction pg 767
When to Discontinue Oxytocin
Operative Assisted Deliveries
Slide 66
Cesarean Birth Indications for
Cesarean Birth (cont)
Slide 69
Cesarean Birth
Post-Op Care
Critical Thinking (4)
POSTPARTUM CARE
Slide 74
Postpartum Psychological Adaptations Reva Rubin
Maternal Responses to Newborn Reva Rubin
Blues vs Dpression
Endocrine Adaptations
Physiological Adaptations
Slide 80
Fundal Assessment
Slide 82
Lochia
Lochia Assessment
Lochia Assessment (2)
Cervix amp Vagina
Perineum
Episiotomy
Other Assessments
Thrombophlebitis
Urinary Retention
Vital Signs
Breast Assessment
Lactation
Discharge Instructions
Postpartum Complications
Hemorrhage
Hemorrhage (cont)
Hematomas
Postpartum Infection
Postpartum Infection (2)
Endometritis
Postpartum Infection (3)
Slide 104
Slide 105
Slide 107
Slide 108
Slide 109
Slide 110
Breastfeeding
Postpartum Psychological Adaptations Reva Rubin
Taking in Mom wants to talk about her experience of labor amp birth preoccupied with her own needs
Taking hold More ready to resume control of her body baby amp taking on mothering role Needs reassurance if inexperienced
Letting-go by 5th week total abandon to NB
Bonding en face position engrossement Encourage through early interaction amp breast-feeding (within 12 hr of birth is best)
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina
Cervix returns to firm nongravid consistency by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum
Assessment turn pt to side in Simrsquos position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy
Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments
Constipation Give stool softeners as ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis
Superficial leg vein diseasendash Ss tenderness in portion of vein local heat amp
redness normal temperature or low-grade feverndash Tx local heat elevate limb bed rest analgesia
elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation
Engorgement day 3 or 4ndash If breastfeeding
Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions
Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Chapter 22--Processes amp Stages of Labor and Birth
Critical Factors In Labor
Passenger
Slide 4
Slide 5
Fetal Lie and Presentation
Slide 7
Passenger (2)
Powers
Onset of labor
False vs True Labor Contractions
False vs True Labor Cervix
Critical Thinking
Stages of Labor First Stage
Slide 15
Slide 16
Slide 17
Dilatation amp Effacement
Care of Laboring Patient Early Labor
Care of Laboring Patient Active Labor
Stages of Labor Second Stage
Slide 22
Head Rotation during Descent
Slide 24
Stages of Labor Third Stage
Critical Thinking (2)
Chapter 23 Intrapartal Nursing Assessment
Initial Intrapartum Assessment Pages 608-612
Intrauterine Fetal Resuscitation
Slide 30
Experiences of Pain
Comfort and Pain Relief
Comfort and Pain Relief (2)
Systemic Analgesia Table 25-3 pg 690
Regional Anesthesia
Slide 36
Medication for Pain Relief Birth
Local anesthesia for Episiotomy
Childbirth at Risk (Ch 26)
Critical Thinking (3)
Precipitous Labor amp Birth
Postterm Pregnancy
Malpresentations
Malpresentations (cont)
External Version
MacrosomiaShoulder Dystocia
Slide 47
McRoberts Maneuvers Video
Multiple Gestation
Multiple Gestation (cont)
Abruptio Placentae
Slide 52
Abruptio Placentae (cont)
Placenta Previa
Slide 55
Prolapsed Cord
Prolapsed Cord (2)
Birth Related Procedures Chapter 27
Methods of Induction
Indications for induction of labor
Contraindications to Induction
Cervical Ripening Assessment
Oxytocin Induction pg 767
When to Discontinue Oxytocin
Operative Assisted Deliveries
Slide 66
Cesarean Birth Indications for
Cesarean Birth (cont)
Slide 69
Cesarean Birth
Post-Op Care
Critical Thinking (4)
POSTPARTUM CARE
Slide 74
Postpartum Psychological Adaptations Reva Rubin
Maternal Responses to Newborn Reva Rubin
Blues vs Dpression
Endocrine Adaptations
Physiological Adaptations
Slide 80
Fundal Assessment
Slide 82
Lochia
Lochia Assessment
Lochia Assessment (2)
Cervix amp Vagina
Perineum
Episiotomy
Other Assessments
Thrombophlebitis
Urinary Retention
Vital Signs
Breast Assessment
Lactation
Discharge Instructions
Postpartum Complications
Hemorrhage
Hemorrhage (cont)
Hematomas
Postpartum Infection
Postpartum Infection (2)
Endometritis
Postpartum Infection (3)
Slide 104
Slide 105
Slide 107
Slide 108
Slide 109
Slide 110
Breastfeeding
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips rarr palming rarrcuddling rarr
Voice- high-pitched amp babies respond Odor- momrsquos respond to babyrsquos unique smell Eye contact- en face position delay eye ointment amp bright lights Nurse role- be able to answer About baby
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina
Cervix returns to firm nongravid consistency by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum
Assessment turn pt to side in Simrsquos position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy
Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments
Constipation Give stool softeners as ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis
Superficial leg vein diseasendash Ss tenderness in portion of vein local heat amp
redness normal temperature or low-grade feverndash Tx local heat elevate limb bed rest analgesia
elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation
Engorgement day 3 or 4ndash If breastfeeding
Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions
Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Chapter 22--Processes amp Stages of Labor and Birth
Critical Factors In Labor
Passenger
Slide 4
Slide 5
Fetal Lie and Presentation
Slide 7
Passenger (2)
Powers
Onset of labor
False vs True Labor Contractions
False vs True Labor Cervix
Critical Thinking
Stages of Labor First Stage
Slide 15
Slide 16
Slide 17
Dilatation amp Effacement
Care of Laboring Patient Early Labor
Care of Laboring Patient Active Labor
Stages of Labor Second Stage
Slide 22
Head Rotation during Descent
Slide 24
Stages of Labor Third Stage
Critical Thinking (2)
Chapter 23 Intrapartal Nursing Assessment
Initial Intrapartum Assessment Pages 608-612
Intrauterine Fetal Resuscitation
Slide 30
Experiences of Pain
Comfort and Pain Relief
Comfort and Pain Relief (2)
Systemic Analgesia Table 25-3 pg 690
Regional Anesthesia
Slide 36
Medication for Pain Relief Birth
Local anesthesia for Episiotomy
Childbirth at Risk (Ch 26)
Critical Thinking (3)
Precipitous Labor amp Birth
Postterm Pregnancy
Malpresentations
Malpresentations (cont)
External Version
MacrosomiaShoulder Dystocia
Slide 47
McRoberts Maneuvers Video
Multiple Gestation
Multiple Gestation (cont)
Abruptio Placentae
Slide 52
Abruptio Placentae (cont)
Placenta Previa
Slide 55
Prolapsed Cord
Prolapsed Cord (2)
Birth Related Procedures Chapter 27
Methods of Induction
Indications for induction of labor
Contraindications to Induction
Cervical Ripening Assessment
Oxytocin Induction pg 767
When to Discontinue Oxytocin
Operative Assisted Deliveries
Slide 66
Cesarean Birth Indications for
Cesarean Birth (cont)
Slide 69
Cesarean Birth
Post-Op Care
Critical Thinking (4)
POSTPARTUM CARE
Slide 74
Postpartum Psychological Adaptations Reva Rubin
Maternal Responses to Newborn Reva Rubin
Blues vs Dpression
Endocrine Adaptations
Physiological Adaptations
Slide 80
Fundal Assessment
Slide 82
Lochia
Lochia Assessment
Lochia Assessment (2)
Cervix amp Vagina
Perineum
Episiotomy
Other Assessments
Thrombophlebitis
Urinary Retention
Vital Signs
Breast Assessment
Lactation
Discharge Instructions
Postpartum Complications
Hemorrhage
Hemorrhage (cont)
Hematomas
Postpartum Infection
Postpartum Infection (2)
Endometritis
Postpartum Infection (3)
Slide 104
Slide 105
Slide 107
Slide 108
Slide 109
Slide 110
Breastfeeding
Blues vs Dpression Postpartumbaby blues transient depression in first few days weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression If persists past 2 weeks or worsens Symptoms very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping Not be able to concentrate Not feel hungry and may lose weight (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby
She may see and hear things that arent there Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby But a woman with postpartum psychosis may feel like she has to act on these thoughts
Endocrine Adaptations Hormones drop after delivery of
placentandash hCG amp hPL gone by 24 hoursndash Estrogen amp progesterone drop within 1 wkndash FSH remains low for 12 days then rises
to begin new cyclendash Sex is ok once lochia is alba Menstrual
period in 6-10 wks ndash Contraception necessary
Physiological Adaptations Uterine involution
ndash umbilicus first 24 hours--should feel firmndash Decreases 1 fingerrsquos breadth per dayndash By 10th day no longer palpable
If high (3 or 4 fingers above U) andor deviated to right have pt void
Risk for delayed involutionndash Multiples hydramnios exhaustion grand
Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina
Cervix returns to firm nongravid consistency by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum
Assessment turn pt to side in Simrsquos position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy
Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments
Constipation Give stool softeners as ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis
Superficial leg vein diseasendash Ss tenderness in portion of vein local heat amp
redness normal temperature or low-grade feverndash Tx local heat elevate limb bed rest analgesia
elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation
Engorgement day 3 or 4ndash If breastfeeding
Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions
Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina
Cervix returns to firm nongravid consistency by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum
Assessment turn pt to side in Simrsquos position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy
Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments
Constipation Give stool softeners as ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis
Superficial leg vein diseasendash Ss tenderness in portion of vein local heat amp
redness normal temperature or low-grade feverndash Tx local heat elevate limb bed rest analgesia
elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation
Engorgement day 3 or 4ndash If breastfeeding
Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions
Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina
Cervix returns to firm nongravid consistency by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum
Assessment turn pt to side in Simrsquos position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy
Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments
Constipation Give stool softeners as ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis
Superficial leg vein diseasendash Ss tenderness in portion of vein local heat amp
redness normal temperature or low-grade feverndash Tx local heat elevate limb bed rest analgesia
elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation
Engorgement day 3 or 4ndash If breastfeeding
Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions
Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Chapter 22--Processes amp Stages of Labor and Birth
Critical Factors In Labor
Passenger
Slide 4
Slide 5
Fetal Lie and Presentation
Slide 7
Passenger (2)
Powers
Onset of labor
False vs True Labor Contractions
False vs True Labor Cervix
Critical Thinking
Stages of Labor First Stage
Slide 15
Slide 16
Slide 17
Dilatation amp Effacement
Care of Laboring Patient Early Labor
Care of Laboring Patient Active Labor
Stages of Labor Second Stage
Slide 22
Head Rotation during Descent
Slide 24
Stages of Labor Third Stage
Critical Thinking (2)
Chapter 23 Intrapartal Nursing Assessment
Initial Intrapartum Assessment Pages 608-612
Intrauterine Fetal Resuscitation
Slide 30
Experiences of Pain
Comfort and Pain Relief
Comfort and Pain Relief (2)
Systemic Analgesia Table 25-3 pg 690
Regional Anesthesia
Slide 36
Medication for Pain Relief Birth
Local anesthesia for Episiotomy
Childbirth at Risk (Ch 26)
Critical Thinking (3)
Precipitous Labor amp Birth
Postterm Pregnancy
Malpresentations
Malpresentations (cont)
External Version
MacrosomiaShoulder Dystocia
Slide 47
McRoberts Maneuvers Video
Multiple Gestation
Multiple Gestation (cont)
Abruptio Placentae
Slide 52
Abruptio Placentae (cont)
Placenta Previa
Slide 55
Prolapsed Cord
Prolapsed Cord (2)
Birth Related Procedures Chapter 27
Methods of Induction
Indications for induction of labor
Contraindications to Induction
Cervical Ripening Assessment
Oxytocin Induction pg 767
When to Discontinue Oxytocin
Operative Assisted Deliveries
Slide 66
Cesarean Birth Indications for
Cesarean Birth (cont)
Slide 69
Cesarean Birth
Post-Op Care
Critical Thinking (4)
POSTPARTUM CARE
Slide 74
Postpartum Psychological Adaptations Reva Rubin
Maternal Responses to Newborn Reva Rubin
Blues vs Dpression
Endocrine Adaptations
Physiological Adaptations
Slide 80
Fundal Assessment
Slide 82
Lochia
Lochia Assessment
Lochia Assessment (2)
Cervix amp Vagina
Perineum
Episiotomy
Other Assessments
Thrombophlebitis
Urinary Retention
Vital Signs
Breast Assessment
Lactation
Discharge Instructions
Postpartum Complications
Hemorrhage
Hemorrhage (cont)
Hematomas
Postpartum Infection
Postpartum Infection (2)
Endometritis
Postpartum Infection (3)
Slide 104
Slide 105
Slide 107
Slide 108
Slide 109
Slide 110
Breastfeeding
Fundal Assessment
Every 10-15 mins in first hour Supine position Palpate one hand at base of uterus amp other at
umbilicus Press inward and downward and feel for firm globular mass
Assess ndash Height (fingers abovebelow umbilicus)ndash Position (midline deviated to right or left)ndash Consistency firm soft boggy
If not firm massage amp should become firm If still boggy notify MDassess for clots hemorrhage Administer oxytocin or other oxytocic (methergine hemabate)
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina
Cervix returns to firm nongravid consistency by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum
Assessment turn pt to side in Simrsquos position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy
Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments
Constipation Give stool softeners as ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis
Superficial leg vein diseasendash Ss tenderness in portion of vein local heat amp
redness normal temperature or low-grade feverndash Tx local heat elevate limb bed rest analgesia
elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation
Engorgement day 3 or 4ndash If breastfeeding
Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions
Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Chapter 22--Processes amp Stages of Labor and Birth
Critical Factors In Labor
Passenger
Slide 4
Slide 5
Fetal Lie and Presentation
Slide 7
Passenger (2)
Powers
Onset of labor
False vs True Labor Contractions
False vs True Labor Cervix
Critical Thinking
Stages of Labor First Stage
Slide 15
Slide 16
Slide 17
Dilatation amp Effacement
Care of Laboring Patient Early Labor
Care of Laboring Patient Active Labor
Stages of Labor Second Stage
Slide 22
Head Rotation during Descent
Slide 24
Stages of Labor Third Stage
Critical Thinking (2)
Chapter 23 Intrapartal Nursing Assessment
Initial Intrapartum Assessment Pages 608-612
Intrauterine Fetal Resuscitation
Slide 30
Experiences of Pain
Comfort and Pain Relief
Comfort and Pain Relief (2)
Systemic Analgesia Table 25-3 pg 690
Regional Anesthesia
Slide 36
Medication for Pain Relief Birth
Local anesthesia for Episiotomy
Childbirth at Risk (Ch 26)
Critical Thinking (3)
Precipitous Labor amp Birth
Postterm Pregnancy
Malpresentations
Malpresentations (cont)
External Version
MacrosomiaShoulder Dystocia
Slide 47
McRoberts Maneuvers Video
Multiple Gestation
Multiple Gestation (cont)
Abruptio Placentae
Slide 52
Abruptio Placentae (cont)
Placenta Previa
Slide 55
Prolapsed Cord
Prolapsed Cord (2)
Birth Related Procedures Chapter 27
Methods of Induction
Indications for induction of labor
Contraindications to Induction
Cervical Ripening Assessment
Oxytocin Induction pg 767
When to Discontinue Oxytocin
Operative Assisted Deliveries
Slide 66
Cesarean Birth Indications for
Cesarean Birth (cont)
Slide 69
Cesarean Birth
Post-Op Care
Critical Thinking (4)
POSTPARTUM CARE
Slide 74
Postpartum Psychological Adaptations Reva Rubin
Maternal Responses to Newborn Reva Rubin
Blues vs Dpression
Endocrine Adaptations
Physiological Adaptations
Slide 80
Fundal Assessment
Slide 82
Lochia
Lochia Assessment
Lochia Assessment (2)
Cervix amp Vagina
Perineum
Episiotomy
Other Assessments
Thrombophlebitis
Urinary Retention
Vital Signs
Breast Assessment
Lactation
Discharge Instructions
Postpartum Complications
Hemorrhage
Hemorrhage (cont)
Hematomas
Postpartum Infection
Postpartum Infection (2)
Endometritis
Postpartum Infection (3)
Slide 104
Slide 105
Slide 107
Slide 108
Slide 109
Slide 110
Breastfeeding
Lochia
Rubra Red day 1-3 blood Serosa Pinkish or brownish day 3-10
blood mucus leukocytes Alba whitish day 10-14 (may last 6 wks)
largely mucus amp leukocytes If flow increases woman should rest more Warning sign if lochia returns to previous
type (alba to serosa or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina
Cervix returns to firm nongravid consistency by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum
Assessment turn pt to side in Simrsquos position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy
Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments
Constipation Give stool softeners as ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis
Superficial leg vein diseasendash Ss tenderness in portion of vein local heat amp
redness normal temperature or low-grade feverndash Tx local heat elevate limb bed rest analgesia
elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation
Engorgement day 3 or 4ndash If breastfeeding
Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions
Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Chapter 22--Processes amp Stages of Labor and Birth
Critical Factors In Labor
Passenger
Slide 4
Slide 5
Fetal Lie and Presentation
Slide 7
Passenger (2)
Powers
Onset of labor
False vs True Labor Contractions
False vs True Labor Cervix
Critical Thinking
Stages of Labor First Stage
Slide 15
Slide 16
Slide 17
Dilatation amp Effacement
Care of Laboring Patient Early Labor
Care of Laboring Patient Active Labor
Stages of Labor Second Stage
Slide 22
Head Rotation during Descent
Slide 24
Stages of Labor Third Stage
Critical Thinking (2)
Chapter 23 Intrapartal Nursing Assessment
Initial Intrapartum Assessment Pages 608-612
Intrauterine Fetal Resuscitation
Slide 30
Experiences of Pain
Comfort and Pain Relief
Comfort and Pain Relief (2)
Systemic Analgesia Table 25-3 pg 690
Regional Anesthesia
Slide 36
Medication for Pain Relief Birth
Local anesthesia for Episiotomy
Childbirth at Risk (Ch 26)
Critical Thinking (3)
Precipitous Labor amp Birth
Postterm Pregnancy
Malpresentations
Malpresentations (cont)
External Version
MacrosomiaShoulder Dystocia
Slide 47
McRoberts Maneuvers Video
Multiple Gestation
Multiple Gestation (cont)
Abruptio Placentae
Slide 52
Abruptio Placentae (cont)
Placenta Previa
Slide 55
Prolapsed Cord
Prolapsed Cord (2)
Birth Related Procedures Chapter 27
Methods of Induction
Indications for induction of labor
Contraindications to Induction
Cervical Ripening Assessment
Oxytocin Induction pg 767
When to Discontinue Oxytocin
Operative Assisted Deliveries
Slide 66
Cesarean Birth Indications for
Cesarean Birth (cont)
Slide 69
Cesarean Birth
Post-Op Care
Critical Thinking (4)
POSTPARTUM CARE
Slide 74
Postpartum Psychological Adaptations Reva Rubin
Maternal Responses to Newborn Reva Rubin
Blues vs Dpression
Endocrine Adaptations
Physiological Adaptations
Slide 80
Fundal Assessment
Slide 82
Lochia
Lochia Assessment
Lochia Assessment (2)
Cervix amp Vagina
Perineum
Episiotomy
Other Assessments
Thrombophlebitis
Urinary Retention
Vital Signs
Breast Assessment
Lactation
Discharge Instructions
Postpartum Complications
Hemorrhage
Hemorrhage (cont)
Hematomas
Postpartum Infection
Postpartum Infection (2)
Endometritis
Postpartum Infection (3)
Slide 104
Slide 105
Slide 107
Slide 108
Slide 109
Slide 110
Breastfeeding
Lochia Assessment
Check q 15 mins in 1st hour Assessment
ndash Color (rubra serosa alba) amount odor presence of clots
ndash Constant trickle of vaginal flow or soaking pad every 60 minutes is more than average Can weigh pads--1 gm = 1 ml of blood
Lochia should not exceed a moderate amount 4 to 8 partially saturated padsday
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina
Cervix returns to firm nongravid consistency by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum
Assessment turn pt to side in Simrsquos position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy
Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments
Constipation Give stool softeners as ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis
Superficial leg vein diseasendash Ss tenderness in portion of vein local heat amp
redness normal temperature or low-grade feverndash Tx local heat elevate limb bed rest analgesia
elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation
Engorgement day 3 or 4ndash If breastfeeding
Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions
Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Chapter 22--Processes amp Stages of Labor and Birth
Critical Factors In Labor
Passenger
Slide 4
Slide 5
Fetal Lie and Presentation
Slide 7
Passenger (2)
Powers
Onset of labor
False vs True Labor Contractions
False vs True Labor Cervix
Critical Thinking
Stages of Labor First Stage
Slide 15
Slide 16
Slide 17
Dilatation amp Effacement
Care of Laboring Patient Early Labor
Care of Laboring Patient Active Labor
Stages of Labor Second Stage
Slide 22
Head Rotation during Descent
Slide 24
Stages of Labor Third Stage
Critical Thinking (2)
Chapter 23 Intrapartal Nursing Assessment
Initial Intrapartum Assessment Pages 608-612
Intrauterine Fetal Resuscitation
Slide 30
Experiences of Pain
Comfort and Pain Relief
Comfort and Pain Relief (2)
Systemic Analgesia Table 25-3 pg 690
Regional Anesthesia
Slide 36
Medication for Pain Relief Birth
Local anesthesia for Episiotomy
Childbirth at Risk (Ch 26)
Critical Thinking (3)
Precipitous Labor amp Birth
Postterm Pregnancy
Malpresentations
Malpresentations (cont)
External Version
MacrosomiaShoulder Dystocia
Slide 47
McRoberts Maneuvers Video
Multiple Gestation
Multiple Gestation (cont)
Abruptio Placentae
Slide 52
Abruptio Placentae (cont)
Placenta Previa
Slide 55
Prolapsed Cord
Prolapsed Cord (2)
Birth Related Procedures Chapter 27
Methods of Induction
Indications for induction of labor
Contraindications to Induction
Cervical Ripening Assessment
Oxytocin Induction pg 767
When to Discontinue Oxytocin
Operative Assisted Deliveries
Slide 66
Cesarean Birth Indications for
Cesarean Birth (cont)
Slide 69
Cesarean Birth
Post-Op Care
Critical Thinking (4)
POSTPARTUM CARE
Slide 74
Postpartum Psychological Adaptations Reva Rubin
Maternal Responses to Newborn Reva Rubin
Blues vs Dpression
Endocrine Adaptations
Physiological Adaptations
Slide 80
Fundal Assessment
Slide 82
Lochia
Lochia Assessment
Lochia Assessment (2)
Cervix amp Vagina
Perineum
Episiotomy
Other Assessments
Thrombophlebitis
Urinary Retention
Vital Signs
Breast Assessment
Lactation
Discharge Instructions
Postpartum Complications
Hemorrhage
Hemorrhage (cont)
Hematomas
Postpartum Infection
Postpartum Infection (2)
Endometritis
Postpartum Infection (3)
Slide 104
Slide 105
Slide 107
Slide 108
Slide 109
Slide 110
Breastfeeding
Lochia Assessment Assessing Amounts
ndash Scant peripad has stain less than 1 inch in length after 1 hour
ndash Small stain less than 4 inches after 1 hour--10-25 mL
ndash Moderate stain less than 6 inches after 1 hour--25-50 mL
Instruct in perineal care ∆ pad frequently hand washing ss of infection amp hemorrhage no tampons
Cervix amp Vagina
Cervix returns to firm nongravid consistency by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum
Assessment turn pt to side in Simrsquos position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy
Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments
Constipation Give stool softeners as ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis
Superficial leg vein diseasendash Ss tenderness in portion of vein local heat amp
redness normal temperature or low-grade feverndash Tx local heat elevate limb bed rest analgesia
elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation
Engorgement day 3 or 4ndash If breastfeeding
Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions
Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Chapter 22--Processes amp Stages of Labor and Birth
Critical Factors In Labor
Passenger
Slide 4
Slide 5
Fetal Lie and Presentation
Slide 7
Passenger (2)
Powers
Onset of labor
False vs True Labor Contractions
False vs True Labor Cervix
Critical Thinking
Stages of Labor First Stage
Slide 15
Slide 16
Slide 17
Dilatation amp Effacement
Care of Laboring Patient Early Labor
Care of Laboring Patient Active Labor
Stages of Labor Second Stage
Slide 22
Head Rotation during Descent
Slide 24
Stages of Labor Third Stage
Critical Thinking (2)
Chapter 23 Intrapartal Nursing Assessment
Initial Intrapartum Assessment Pages 608-612
Intrauterine Fetal Resuscitation
Slide 30
Experiences of Pain
Comfort and Pain Relief
Comfort and Pain Relief (2)
Systemic Analgesia Table 25-3 pg 690
Regional Anesthesia
Slide 36
Medication for Pain Relief Birth
Local anesthesia for Episiotomy
Childbirth at Risk (Ch 26)
Critical Thinking (3)
Precipitous Labor amp Birth
Postterm Pregnancy
Malpresentations
Malpresentations (cont)
External Version
MacrosomiaShoulder Dystocia
Slide 47
McRoberts Maneuvers Video
Multiple Gestation
Multiple Gestation (cont)
Abruptio Placentae
Slide 52
Abruptio Placentae (cont)
Placenta Previa
Slide 55
Prolapsed Cord
Prolapsed Cord (2)
Birth Related Procedures Chapter 27
Methods of Induction
Indications for induction of labor
Contraindications to Induction
Cervical Ripening Assessment
Oxytocin Induction pg 767
When to Discontinue Oxytocin
Operative Assisted Deliveries
Slide 66
Cesarean Birth Indications for
Cesarean Birth (cont)
Slide 69
Cesarean Birth
Post-Op Care
Critical Thinking (4)
POSTPARTUM CARE
Slide 74
Postpartum Psychological Adaptations Reva Rubin
Maternal Responses to Newborn Reva Rubin
Blues vs Dpression
Endocrine Adaptations
Physiological Adaptations
Slide 80
Fundal Assessment
Slide 82
Lochia
Lochia Assessment
Lochia Assessment (2)
Cervix amp Vagina
Perineum
Episiotomy
Other Assessments
Thrombophlebitis
Urinary Retention
Vital Signs
Breast Assessment
Lactation
Discharge Instructions
Postpartum Complications
Hemorrhage
Hemorrhage (cont)
Hematomas
Postpartum Infection
Postpartum Infection (2)
Endometritis
Postpartum Infection (3)
Slide 104
Slide 105
Slide 107
Slide 108
Slide 109
Slide 110
Breastfeeding
Cervix amp Vagina
Cervix returns to firm nongravid consistency by about 7 days but external os remains slit-like or stellate
Vagina involutes in 6 wk period with return of rugae ndash Kegel exercises for pelvic floor muscles
Isolate muscles to contract by stopping flow of urine while urinating
Contract these muscles in sets of 10 or 20 3 times per day
Perineum
Assessment turn pt to side in Simrsquos position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy
Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments
Constipation Give stool softeners as ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis
Superficial leg vein diseasendash Ss tenderness in portion of vein local heat amp
redness normal temperature or low-grade feverndash Tx local heat elevate limb bed rest analgesia
elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation
Engorgement day 3 or 4ndash If breastfeeding
Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions
Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Chapter 22--Processes amp Stages of Labor and Birth
Critical Factors In Labor
Passenger
Slide 4
Slide 5
Fetal Lie and Presentation
Slide 7
Passenger (2)
Powers
Onset of labor
False vs True Labor Contractions
False vs True Labor Cervix
Critical Thinking
Stages of Labor First Stage
Slide 15
Slide 16
Slide 17
Dilatation amp Effacement
Care of Laboring Patient Early Labor
Care of Laboring Patient Active Labor
Stages of Labor Second Stage
Slide 22
Head Rotation during Descent
Slide 24
Stages of Labor Third Stage
Critical Thinking (2)
Chapter 23 Intrapartal Nursing Assessment
Initial Intrapartum Assessment Pages 608-612
Intrauterine Fetal Resuscitation
Slide 30
Experiences of Pain
Comfort and Pain Relief
Comfort and Pain Relief (2)
Systemic Analgesia Table 25-3 pg 690
Regional Anesthesia
Slide 36
Medication for Pain Relief Birth
Local anesthesia for Episiotomy
Childbirth at Risk (Ch 26)
Critical Thinking (3)
Precipitous Labor amp Birth
Postterm Pregnancy
Malpresentations
Malpresentations (cont)
External Version
MacrosomiaShoulder Dystocia
Slide 47
McRoberts Maneuvers Video
Multiple Gestation
Multiple Gestation (cont)
Abruptio Placentae
Slide 52
Abruptio Placentae (cont)
Placenta Previa
Slide 55
Prolapsed Cord
Prolapsed Cord (2)
Birth Related Procedures Chapter 27
Methods of Induction
Indications for induction of labor
Contraindications to Induction
Cervical Ripening Assessment
Oxytocin Induction pg 767
When to Discontinue Oxytocin
Operative Assisted Deliveries
Slide 66
Cesarean Birth Indications for
Cesarean Birth (cont)
Slide 69
Cesarean Birth
Post-Op Care
Critical Thinking (4)
POSTPARTUM CARE
Slide 74
Postpartum Psychological Adaptations Reva Rubin
Maternal Responses to Newborn Reva Rubin
Blues vs Dpression
Endocrine Adaptations
Physiological Adaptations
Slide 80
Fundal Assessment
Slide 82
Lochia
Lochia Assessment
Lochia Assessment (2)
Cervix amp Vagina
Perineum
Episiotomy
Other Assessments
Thrombophlebitis
Urinary Retention
Vital Signs
Breast Assessment
Lactation
Discharge Instructions
Postpartum Complications
Hemorrhage
Hemorrhage (cont)
Hematomas
Postpartum Infection
Postpartum Infection (2)
Endometritis
Postpartum Infection (3)
Slide 104
Slide 105
Slide 107
Slide 108
Slide 109
Slide 110
Breastfeeding
Perineum
Assessment turn pt to side in Simrsquos position Lift upper buttock and assess forndash Ecchymosis hematoma erythema
edema intactness approximation drainage or bleeding from stitches
Assess for hemorrhoids amp document number appearance amp size
Episiotomy
Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments
Constipation Give stool softeners as ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis
Superficial leg vein diseasendash Ss tenderness in portion of vein local heat amp
redness normal temperature or low-grade feverndash Tx local heat elevate limb bed rest analgesia
elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation
Engorgement day 3 or 4ndash If breastfeeding
Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions
Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Chapter 22--Processes amp Stages of Labor and Birth
Critical Factors In Labor
Passenger
Slide 4
Slide 5
Fetal Lie and Presentation
Slide 7
Passenger (2)
Powers
Onset of labor
False vs True Labor Contractions
False vs True Labor Cervix
Critical Thinking
Stages of Labor First Stage
Slide 15
Slide 16
Slide 17
Dilatation amp Effacement
Care of Laboring Patient Early Labor
Care of Laboring Patient Active Labor
Stages of Labor Second Stage
Slide 22
Head Rotation during Descent
Slide 24
Stages of Labor Third Stage
Critical Thinking (2)
Chapter 23 Intrapartal Nursing Assessment
Initial Intrapartum Assessment Pages 608-612
Intrauterine Fetal Resuscitation
Slide 30
Experiences of Pain
Comfort and Pain Relief
Comfort and Pain Relief (2)
Systemic Analgesia Table 25-3 pg 690
Regional Anesthesia
Slide 36
Medication for Pain Relief Birth
Local anesthesia for Episiotomy
Childbirth at Risk (Ch 26)
Critical Thinking (3)
Precipitous Labor amp Birth
Postterm Pregnancy
Malpresentations
Malpresentations (cont)
External Version
MacrosomiaShoulder Dystocia
Slide 47
McRoberts Maneuvers Video
Multiple Gestation
Multiple Gestation (cont)
Abruptio Placentae
Slide 52
Abruptio Placentae (cont)
Placenta Previa
Slide 55
Prolapsed Cord
Prolapsed Cord (2)
Birth Related Procedures Chapter 27
Methods of Induction
Indications for induction of labor
Contraindications to Induction
Cervical Ripening Assessment
Oxytocin Induction pg 767
When to Discontinue Oxytocin
Operative Assisted Deliveries
Slide 66
Cesarean Birth Indications for
Cesarean Birth (cont)
Slide 69
Cesarean Birth
Post-Op Care
Critical Thinking (4)
POSTPARTUM CARE
Slide 74
Postpartum Psychological Adaptations Reva Rubin
Maternal Responses to Newborn Reva Rubin
Blues vs Dpression
Endocrine Adaptations
Physiological Adaptations
Slide 80
Fundal Assessment
Slide 82
Lochia
Lochia Assessment
Lochia Assessment (2)
Cervix amp Vagina
Perineum
Episiotomy
Other Assessments
Thrombophlebitis
Urinary Retention
Vital Signs
Breast Assessment
Lactation
Discharge Instructions
Postpartum Complications
Hemorrhage
Hemorrhage (cont)
Hematomas
Postpartum Infection
Postpartum Infection (2)
Endometritis
Postpartum Infection (3)
Slide 104
Slide 105
Slide 107
Slide 108
Slide 109
Slide 110
Breastfeeding
Episiotomy
Midline or mediolateral Nursing care
ndash Assess for approximation swelling oozing infection
ndash Relief for pain ice pack in first 24 hours then heat local analgesic spray witch hazel pads (Tucks) sitz bath peri-bottle for voiding pain medications
Other Assessments
Constipation Give stool softeners as ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis
Superficial leg vein diseasendash Ss tenderness in portion of vein local heat amp
redness normal temperature or low-grade feverndash Tx local heat elevate limb bed rest analgesia
elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation
Engorgement day 3 or 4ndash If breastfeeding
Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions
Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Chapter 22--Processes amp Stages of Labor and Birth
Critical Factors In Labor
Passenger
Slide 4
Slide 5
Fetal Lie and Presentation
Slide 7
Passenger (2)
Powers
Onset of labor
False vs True Labor Contractions
False vs True Labor Cervix
Critical Thinking
Stages of Labor First Stage
Slide 15
Slide 16
Slide 17
Dilatation amp Effacement
Care of Laboring Patient Early Labor
Care of Laboring Patient Active Labor
Stages of Labor Second Stage
Slide 22
Head Rotation during Descent
Slide 24
Stages of Labor Third Stage
Critical Thinking (2)
Chapter 23 Intrapartal Nursing Assessment
Initial Intrapartum Assessment Pages 608-612
Intrauterine Fetal Resuscitation
Slide 30
Experiences of Pain
Comfort and Pain Relief
Comfort and Pain Relief (2)
Systemic Analgesia Table 25-3 pg 690
Regional Anesthesia
Slide 36
Medication for Pain Relief Birth
Local anesthesia for Episiotomy
Childbirth at Risk (Ch 26)
Critical Thinking (3)
Precipitous Labor amp Birth
Postterm Pregnancy
Malpresentations
Malpresentations (cont)
External Version
MacrosomiaShoulder Dystocia
Slide 47
McRoberts Maneuvers Video
Multiple Gestation
Multiple Gestation (cont)
Abruptio Placentae
Slide 52
Abruptio Placentae (cont)
Placenta Previa
Slide 55
Prolapsed Cord
Prolapsed Cord (2)
Birth Related Procedures Chapter 27
Methods of Induction
Indications for induction of labor
Contraindications to Induction
Cervical Ripening Assessment
Oxytocin Induction pg 767
When to Discontinue Oxytocin
Operative Assisted Deliveries
Slide 66
Cesarean Birth Indications for
Cesarean Birth (cont)
Slide 69
Cesarean Birth
Post-Op Care
Critical Thinking (4)
POSTPARTUM CARE
Slide 74
Postpartum Psychological Adaptations Reva Rubin
Maternal Responses to Newborn Reva Rubin
Blues vs Dpression
Endocrine Adaptations
Physiological Adaptations
Slide 80
Fundal Assessment
Slide 82
Lochia
Lochia Assessment
Lochia Assessment (2)
Cervix amp Vagina
Perineum
Episiotomy
Other Assessments
Thrombophlebitis
Urinary Retention
Vital Signs
Breast Assessment
Lactation
Discharge Instructions
Postpartum Complications
Hemorrhage
Hemorrhage (cont)
Hematomas
Postpartum Infection
Postpartum Infection (2)
Endometritis
Postpartum Infection (3)
Slide 104
Slide 105
Slide 107
Slide 108
Slide 109
Slide 110
Breastfeeding
Other Assessments
Constipation Give stool softeners as ordered prune juice encourage ambulation adequate fluid intake fiber in diet
Homanrsquos sign assess calves for redness warmth pain swelling
-uarrrisk of DVT thrombophlebitis -Occur in postpartum because
ndash Fibrinogin level is elevatedndash Dilatation of lower extremity veinsndash Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling stasis amp clotting of blood in lower extremities
Thrombophlebitis
Superficial leg vein diseasendash Ss tenderness in portion of vein local heat amp
redness normal temperature or low-grade feverndash Tx local heat elevate limb bed rest analgesia
elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation
Engorgement day 3 or 4ndash If breastfeeding
Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions
Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Chapter 22--Processes amp Stages of Labor and Birth
Critical Factors In Labor
Passenger
Slide 4
Slide 5
Fetal Lie and Presentation
Slide 7
Passenger (2)
Powers
Onset of labor
False vs True Labor Contractions
False vs True Labor Cervix
Critical Thinking
Stages of Labor First Stage
Slide 15
Slide 16
Slide 17
Dilatation amp Effacement
Care of Laboring Patient Early Labor
Care of Laboring Patient Active Labor
Stages of Labor Second Stage
Slide 22
Head Rotation during Descent
Slide 24
Stages of Labor Third Stage
Critical Thinking (2)
Chapter 23 Intrapartal Nursing Assessment
Initial Intrapartum Assessment Pages 608-612
Intrauterine Fetal Resuscitation
Slide 30
Experiences of Pain
Comfort and Pain Relief
Comfort and Pain Relief (2)
Systemic Analgesia Table 25-3 pg 690
Regional Anesthesia
Slide 36
Medication for Pain Relief Birth
Local anesthesia for Episiotomy
Childbirth at Risk (Ch 26)
Critical Thinking (3)
Precipitous Labor amp Birth
Postterm Pregnancy
Malpresentations
Malpresentations (cont)
External Version
MacrosomiaShoulder Dystocia
Slide 47
McRoberts Maneuvers Video
Multiple Gestation
Multiple Gestation (cont)
Abruptio Placentae
Slide 52
Abruptio Placentae (cont)
Placenta Previa
Slide 55
Prolapsed Cord
Prolapsed Cord (2)
Birth Related Procedures Chapter 27
Methods of Induction
Indications for induction of labor
Contraindications to Induction
Cervical Ripening Assessment
Oxytocin Induction pg 767
When to Discontinue Oxytocin
Operative Assisted Deliveries
Slide 66
Cesarean Birth Indications for
Cesarean Birth (cont)
Slide 69
Cesarean Birth
Post-Op Care
Critical Thinking (4)
POSTPARTUM CARE
Slide 74
Postpartum Psychological Adaptations Reva Rubin
Maternal Responses to Newborn Reva Rubin
Blues vs Dpression
Endocrine Adaptations
Physiological Adaptations
Slide 80
Fundal Assessment
Slide 82
Lochia
Lochia Assessment
Lochia Assessment (2)
Cervix amp Vagina
Perineum
Episiotomy
Other Assessments
Thrombophlebitis
Urinary Retention
Vital Signs
Breast Assessment
Lactation
Discharge Instructions
Postpartum Complications
Hemorrhage
Hemorrhage (cont)
Hematomas
Postpartum Infection
Postpartum Infection (2)
Endometritis
Postpartum Infection (3)
Slide 104
Slide 105
Slide 107
Slide 108
Slide 109
Slide 110
Breastfeeding
Thrombophlebitis
Superficial leg vein diseasendash Ss tenderness in portion of vein local heat amp
redness normal temperature or low-grade feverndash Tx local heat elevate limb bed rest analgesia
elastic support hose
Deep Vein Thrombosis (DVT)ndash Ss edema of ankle leg initial low-grade fever
then high temperature amp chills tenderness amp pain changes in limb color amp difference in circumference
ndash Tx IV heparin bed rest elevation of leg analgesics warm moist heat antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation
Engorgement day 3 or 4ndash If breastfeeding
Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions
Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Chapter 22--Processes amp Stages of Labor and Birth
Critical Factors In Labor
Passenger
Slide 4
Slide 5
Fetal Lie and Presentation
Slide 7
Passenger (2)
Powers
Onset of labor
False vs True Labor Contractions
False vs True Labor Cervix
Critical Thinking
Stages of Labor First Stage
Slide 15
Slide 16
Slide 17
Dilatation amp Effacement
Care of Laboring Patient Early Labor
Care of Laboring Patient Active Labor
Stages of Labor Second Stage
Slide 22
Head Rotation during Descent
Slide 24
Stages of Labor Third Stage
Critical Thinking (2)
Chapter 23 Intrapartal Nursing Assessment
Initial Intrapartum Assessment Pages 608-612
Intrauterine Fetal Resuscitation
Slide 30
Experiences of Pain
Comfort and Pain Relief
Comfort and Pain Relief (2)
Systemic Analgesia Table 25-3 pg 690
Regional Anesthesia
Slide 36
Medication for Pain Relief Birth
Local anesthesia for Episiotomy
Childbirth at Risk (Ch 26)
Critical Thinking (3)
Precipitous Labor amp Birth
Postterm Pregnancy
Malpresentations
Malpresentations (cont)
External Version
MacrosomiaShoulder Dystocia
Slide 47
McRoberts Maneuvers Video
Multiple Gestation
Multiple Gestation (cont)
Abruptio Placentae
Slide 52
Abruptio Placentae (cont)
Placenta Previa
Slide 55
Prolapsed Cord
Prolapsed Cord (2)
Birth Related Procedures Chapter 27
Methods of Induction
Indications for induction of labor
Contraindications to Induction
Cervical Ripening Assessment
Oxytocin Induction pg 767
When to Discontinue Oxytocin
Operative Assisted Deliveries
Slide 66
Cesarean Birth Indications for
Cesarean Birth (cont)
Slide 69
Cesarean Birth
Post-Op Care
Critical Thinking (4)
POSTPARTUM CARE
Slide 74
Postpartum Psychological Adaptations Reva Rubin
Maternal Responses to Newborn Reva Rubin
Blues vs Dpression
Endocrine Adaptations
Physiological Adaptations
Slide 80
Fundal Assessment
Slide 82
Lochia
Lochia Assessment
Lochia Assessment (2)
Cervix amp Vagina
Perineum
Episiotomy
Other Assessments
Thrombophlebitis
Urinary Retention
Vital Signs
Breast Assessment
Lactation
Discharge Instructions
Postpartum Complications
Hemorrhage
Hemorrhage (cont)
Hematomas
Postpartum Infection
Postpartum Infection (2)
Endometritis
Postpartum Infection (3)
Slide 104
Slide 105
Slide 107
Slide 108
Slide 109
Slide 110
Breastfeeding
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder amp urethra during birth or anesthesia may cause loss of tone difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention Check fundus to see if bladder is full If unable to void catheterize Monitor for UTI
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration If 1004 or above suspect infection
Rapid or thready pulse--sign of hemorrhage BP monitor--still at risk of PIH Methergine
(oxytocic) can uarrBP darrBP could be sign of hemorrhagendash Can have orthostatic hypotension due to blood
loss Assist pt with first trip to BR Instruct pt to dangle legs and sit first before rising If dizzy do not ambulate
Breast Assessment Breasts
ndash Soft Soft on palpation day 1 amp 2ndash Filling firmer amp warmth day 3ndash Engorged appear large reddened taut
shiny skin warm hard tense amp tenderpainful on palpation
ndash Mastitis (infection) only one part of breast is warmreddened--UNILATERAL
Nipples look for cracking fissures blisters pain
Lactation
Engorgement day 3 or 4ndash If breastfeeding
Encourage frequent breastfeedingWarm compresses or warm shower
ndash If not breastfeedingCold compressesice snug bra or breast
binder oral analgesics Breast care
ndash Wash daily with water and air dry ndashNO SOAPndash Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy Avoid underwires Use cotton nursing pads for leaking--keep nipples dry
Discharge Instructions
Avoidlimit heavy lifting stairs Good diet increase fluids if
breastfeeding Adequate rest exerciseactivity as
tolerated Report fever foul smelling discharge
increased pain or bleeding to MD Sexcontraception Follow up in 6 weeks with MD
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
manual exploration of uterus uterine packing D amp C hysterectomy
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Chapter 22--Processes amp Stages of Labor and Birth
Critical Factors In Labor
Passenger
Slide 4
Slide 5
Fetal Lie and Presentation
Slide 7
Passenger (2)
Powers
Onset of labor
False vs True Labor Contractions
False vs True Labor Cervix
Critical Thinking
Stages of Labor First Stage
Slide 15
Slide 16
Slide 17
Dilatation amp Effacement
Care of Laboring Patient Early Labor
Care of Laboring Patient Active Labor
Stages of Labor Second Stage
Slide 22
Head Rotation during Descent
Slide 24
Stages of Labor Third Stage
Critical Thinking (2)
Chapter 23 Intrapartal Nursing Assessment
Initial Intrapartum Assessment Pages 608-612
Intrauterine Fetal Resuscitation
Slide 30
Experiences of Pain
Comfort and Pain Relief
Comfort and Pain Relief (2)
Systemic Analgesia Table 25-3 pg 690
Regional Anesthesia
Slide 36
Medication for Pain Relief Birth
Local anesthesia for Episiotomy
Childbirth at Risk (Ch 26)
Critical Thinking (3)
Precipitous Labor amp Birth
Postterm Pregnancy
Malpresentations
Malpresentations (cont)
External Version
MacrosomiaShoulder Dystocia
Slide 47
McRoberts Maneuvers Video
Multiple Gestation
Multiple Gestation (cont)
Abruptio Placentae
Slide 52
Abruptio Placentae (cont)
Placenta Previa
Slide 55
Prolapsed Cord
Prolapsed Cord (2)
Birth Related Procedures Chapter 27
Methods of Induction
Indications for induction of labor
Contraindications to Induction
Cervical Ripening Assessment
Oxytocin Induction pg 767
When to Discontinue Oxytocin
Operative Assisted Deliveries
Slide 66
Cesarean Birth Indications for
Cesarean Birth (cont)
Slide 69
Cesarean Birth
Post-Op Care
Critical Thinking (4)
POSTPARTUM CARE
Slide 74
Postpartum Psychological Adaptations Reva Rubin
Maternal Responses to Newborn Reva Rubin
Blues vs Dpression
Endocrine Adaptations
Physiological Adaptations
Slide 80
Fundal Assessment
Slide 82
Lochia
Lochia Assessment
Lochia Assessment (2)
Cervix amp Vagina
Perineum
Episiotomy
Other Assessments
Thrombophlebitis
Urinary Retention
Vital Signs
Breast Assessment
Lactation
Discharge Instructions
Postpartum Complications
Hemorrhage
Hemorrhage (cont)
Hematomas
Postpartum Infection
Postpartum Infection (2)
Endometritis
Postpartum Infection (3)
Slide 104
Slide 105
Slide 107
Slide 108
Slide 109
Slide 110
Breastfeeding
Hemorrhage (cont)
Lacerations cervical vaginal perineal
Retained placental fragments ndash can occur well after delivery Maternal serum test
for hCG or US Possible DampCndash May see symptoms even after 1 week
Subinvolution retained placenta infection fibroidsndash PO methergine antibiotic
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Chapter 22--Processes amp Stages of Labor and Birth
Critical Factors In Labor
Passenger
Slide 4
Slide 5
Fetal Lie and Presentation
Slide 7
Passenger (2)
Powers
Onset of labor
False vs True Labor Contractions
False vs True Labor Cervix
Critical Thinking
Stages of Labor First Stage
Slide 15
Slide 16
Slide 17
Dilatation amp Effacement
Care of Laboring Patient Early Labor
Care of Laboring Patient Active Labor
Stages of Labor Second Stage
Slide 22
Head Rotation during Descent
Slide 24
Stages of Labor Third Stage
Critical Thinking (2)
Chapter 23 Intrapartal Nursing Assessment
Initial Intrapartum Assessment Pages 608-612
Intrauterine Fetal Resuscitation
Slide 30
Experiences of Pain
Comfort and Pain Relief
Comfort and Pain Relief (2)
Systemic Analgesia Table 25-3 pg 690
Regional Anesthesia
Slide 36
Medication for Pain Relief Birth
Local anesthesia for Episiotomy
Childbirth at Risk (Ch 26)
Critical Thinking (3)
Precipitous Labor amp Birth
Postterm Pregnancy
Malpresentations
Malpresentations (cont)
External Version
MacrosomiaShoulder Dystocia
Slide 47
McRoberts Maneuvers Video
Multiple Gestation
Multiple Gestation (cont)
Abruptio Placentae
Slide 52
Abruptio Placentae (cont)
Placenta Previa
Slide 55
Prolapsed Cord
Prolapsed Cord (2)
Birth Related Procedures Chapter 27
Methods of Induction
Indications for induction of labor
Contraindications to Induction
Cervical Ripening Assessment
Oxytocin Induction pg 767
When to Discontinue Oxytocin
Operative Assisted Deliveries
Slide 66
Cesarean Birth Indications for
Cesarean Birth (cont)
Slide 69
Cesarean Birth
Post-Op Care
Critical Thinking (4)
POSTPARTUM CARE
Slide 74
Postpartum Psychological Adaptations Reva Rubin
Maternal Responses to Newborn Reva Rubin
Blues vs Dpression
Endocrine Adaptations
Physiological Adaptations
Slide 80
Fundal Assessment
Slide 82
Lochia
Lochia Assessment
Lochia Assessment (2)
Cervix amp Vagina
Perineum
Episiotomy
Other Assessments
Thrombophlebitis
Urinary Retention
Vital Signs
Breast Assessment
Lactation
Discharge Instructions
Postpartum Complications
Hemorrhage
Hemorrhage (cont)
Hematomas
Postpartum Infection
Postpartum Infection (2)
Endometritis
Postpartum Infection (3)
Slide 104
Slide 105
Slide 107
Slide 108
Slide 109
Slide 110
Breastfeeding
Hematomas CauseTrauma during the birth process Puerperal hematomas occur in 1300 to 11500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy however a hematoma may also result from injury to a blood vessel in the absence of lacerationincision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva vaginalparavaginal area and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams preeclampsia prolonged second stage of labor multifetal pregnancy vulvar varicosities or clotting disorders
Assessment location size vital signs pain HampH Treatment evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Chapter 22--Processes amp Stages of Labor and Birth
Critical Factors In Labor
Passenger
Slide 4
Slide 5
Fetal Lie and Presentation
Slide 7
Passenger (2)
Powers
Onset of labor
False vs True Labor Contractions
False vs True Labor Cervix
Critical Thinking
Stages of Labor First Stage
Slide 15
Slide 16
Slide 17
Dilatation amp Effacement
Care of Laboring Patient Early Labor
Care of Laboring Patient Active Labor
Stages of Labor Second Stage
Slide 22
Head Rotation during Descent
Slide 24
Stages of Labor Third Stage
Critical Thinking (2)
Chapter 23 Intrapartal Nursing Assessment
Initial Intrapartum Assessment Pages 608-612
Intrauterine Fetal Resuscitation
Slide 30
Experiences of Pain
Comfort and Pain Relief
Comfort and Pain Relief (2)
Systemic Analgesia Table 25-3 pg 690
Regional Anesthesia
Slide 36
Medication for Pain Relief Birth
Local anesthesia for Episiotomy
Childbirth at Risk (Ch 26)
Critical Thinking (3)
Precipitous Labor amp Birth
Postterm Pregnancy
Malpresentations
Malpresentations (cont)
External Version
MacrosomiaShoulder Dystocia
Slide 47
McRoberts Maneuvers Video
Multiple Gestation
Multiple Gestation (cont)
Abruptio Placentae
Slide 52
Abruptio Placentae (cont)
Placenta Previa
Slide 55
Prolapsed Cord
Prolapsed Cord (2)
Birth Related Procedures Chapter 27
Methods of Induction
Indications for induction of labor
Contraindications to Induction
Cervical Ripening Assessment
Oxytocin Induction pg 767
When to Discontinue Oxytocin
Operative Assisted Deliveries
Slide 66
Cesarean Birth Indications for
Cesarean Birth (cont)
Slide 69
Cesarean Birth
Post-Op Care
Critical Thinking (4)
POSTPARTUM CARE
Slide 74
Postpartum Psychological Adaptations Reva Rubin
Maternal Responses to Newborn Reva Rubin
Blues vs Dpression
Endocrine Adaptations
Physiological Adaptations
Slide 80
Fundal Assessment
Slide 82
Lochia
Lochia Assessment
Lochia Assessment (2)
Cervix amp Vagina
Perineum
Episiotomy
Other Assessments
Thrombophlebitis
Urinary Retention
Vital Signs
Breast Assessment
Lactation
Discharge Instructions
Postpartum Complications
Hemorrhage
Hemorrhage (cont)
Hematomas
Postpartum Infection
Postpartum Infection (2)
Endometritis
Postpartum Infection (3)
Slide 104
Slide 105
Slide 107
Slide 108
Slide 109
Slide 110
Breastfeeding
Postpartum Infection
Puerperal Infection Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with
ndash C-sectionndash Prolonged ROM chorioamnionitisndash Retained placental fragmentsndash Preexisting anemiandash Prolongeddifficult birth instrumental birthndash Internal fetal monitoring or IUPCndash Uterus explored after birthmanual removal of
placentandash Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Chapter 22--Processes amp Stages of Labor and Birth
Critical Factors In Labor
Passenger
Slide 4
Slide 5
Fetal Lie and Presentation
Slide 7
Passenger (2)
Powers
Onset of labor
False vs True Labor Contractions
False vs True Labor Cervix
Critical Thinking
Stages of Labor First Stage
Slide 15
Slide 16
Slide 17
Dilatation amp Effacement
Care of Laboring Patient Early Labor
Care of Laboring Patient Active Labor
Stages of Labor Second Stage
Slide 22
Head Rotation during Descent
Slide 24
Stages of Labor Third Stage
Critical Thinking (2)
Chapter 23 Intrapartal Nursing Assessment
Initial Intrapartum Assessment Pages 608-612
Intrauterine Fetal Resuscitation
Slide 30
Experiences of Pain
Comfort and Pain Relief
Comfort and Pain Relief (2)
Systemic Analgesia Table 25-3 pg 690
Regional Anesthesia
Slide 36
Medication for Pain Relief Birth
Local anesthesia for Episiotomy
Childbirth at Risk (Ch 26)
Critical Thinking (3)
Precipitous Labor amp Birth
Postterm Pregnancy
Malpresentations
Malpresentations (cont)
External Version
MacrosomiaShoulder Dystocia
Slide 47
McRoberts Maneuvers Video
Multiple Gestation
Multiple Gestation (cont)
Abruptio Placentae
Slide 52
Abruptio Placentae (cont)
Placenta Previa
Slide 55
Prolapsed Cord
Prolapsed Cord (2)
Birth Related Procedures Chapter 27
Methods of Induction
Indications for induction of labor
Contraindications to Induction
Cervical Ripening Assessment
Oxytocin Induction pg 767
When to Discontinue Oxytocin
Operative Assisted Deliveries
Slide 66
Cesarean Birth Indications for
Cesarean Birth (cont)
Slide 69
Cesarean Birth
Post-Op Care
Critical Thinking (4)
POSTPARTUM CARE
Slide 74
Postpartum Psychological Adaptations Reva Rubin
Maternal Responses to Newborn Reva Rubin
Blues vs Dpression
Endocrine Adaptations
Physiological Adaptations
Slide 80
Fundal Assessment
Slide 82
Lochia
Lochia Assessment
Lochia Assessment (2)
Cervix amp Vagina
Perineum
Episiotomy
Other Assessments
Thrombophlebitis
Urinary Retention
Vital Signs
Breast Assessment
Lactation
Discharge Instructions
Postpartum Complications
Hemorrhage
Hemorrhage (cont)
Hematomas
Postpartum Infection
Postpartum Infection (2)
Endometritis
Postpartum Infection (3)
Slide 104
Slide 105
Slide 107
Slide 108
Slide 109
Slide 110
Breastfeeding
Postpartum Infection
Endometritis infection of endometriumndash Associated with chorioamnionitis amp C-
section ndash SS foul-smelling bloody vaginal
discharge fever (day 3 or 4) uterine tenderness tachycardia chills (Elevated temp in 1st 24 hours and elevated WBCs are normal findings)
ndash Can progress to pelvic cellulitis or peritonitis
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Chapter 22--Processes amp Stages of Labor and Birth
Critical Factors In Labor
Passenger
Slide 4
Slide 5
Fetal Lie and Presentation
Slide 7
Passenger (2)
Powers
Onset of labor
False vs True Labor Contractions
False vs True Labor Cervix
Critical Thinking
Stages of Labor First Stage
Slide 15
Slide 16
Slide 17
Dilatation amp Effacement
Care of Laboring Patient Early Labor
Care of Laboring Patient Active Labor
Stages of Labor Second Stage
Slide 22
Head Rotation during Descent
Slide 24
Stages of Labor Third Stage
Critical Thinking (2)
Chapter 23 Intrapartal Nursing Assessment
Initial Intrapartum Assessment Pages 608-612
Intrauterine Fetal Resuscitation
Slide 30
Experiences of Pain
Comfort and Pain Relief
Comfort and Pain Relief (2)
Systemic Analgesia Table 25-3 pg 690
Regional Anesthesia
Slide 36
Medication for Pain Relief Birth
Local anesthesia for Episiotomy
Childbirth at Risk (Ch 26)
Critical Thinking (3)
Precipitous Labor amp Birth
Postterm Pregnancy
Malpresentations
Malpresentations (cont)
External Version
MacrosomiaShoulder Dystocia
Slide 47
McRoberts Maneuvers Video
Multiple Gestation
Multiple Gestation (cont)
Abruptio Placentae
Slide 52
Abruptio Placentae (cont)
Placenta Previa
Slide 55
Prolapsed Cord
Prolapsed Cord (2)
Birth Related Procedures Chapter 27
Methods of Induction
Indications for induction of labor
Contraindications to Induction
Cervical Ripening Assessment
Oxytocin Induction pg 767
When to Discontinue Oxytocin
Operative Assisted Deliveries
Slide 66
Cesarean Birth Indications for
Cesarean Birth (cont)
Slide 69
Cesarean Birth
Post-Op Care
Critical Thinking (4)
POSTPARTUM CARE
Slide 74
Postpartum Psychological Adaptations Reva Rubin
Maternal Responses to Newborn Reva Rubin
Blues vs Dpression
Endocrine Adaptations
Physiological Adaptations
Slide 80
Fundal Assessment
Slide 82
Lochia
Lochia Assessment
Lochia Assessment (2)
Cervix amp Vagina
Perineum
Episiotomy
Other Assessments
Thrombophlebitis
Urinary Retention
Vital Signs
Breast Assessment
Lactation
Discharge Instructions
Postpartum Complications
Hemorrhage
Hemorrhage (cont)
Hematomas
Postpartum Infection
Postpartum Infection (2)
Endometritis
Postpartum Infection (3)
Slide 104
Slide 105
Slide 107
Slide 108
Slide 109
Slide 110
Breastfeeding
Endometritis TX antibiotics as determined by culture of
lochia oxytocics such as methergine if necessary uarr fluid intake pain relief
Nursing considerations Fowlerrsquos position or walking encourages drainage by gravity gloves strict handwashing
Usual course is 7-10 days May result in tubal scarring amp interfere with
future fertility
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Chapter 22--Processes amp Stages of Labor and Birth
Critical Factors In Labor
Passenger
Slide 4
Slide 5
Fetal Lie and Presentation
Slide 7
Passenger (2)
Powers
Onset of labor
False vs True Labor Contractions
False vs True Labor Cervix
Critical Thinking
Stages of Labor First Stage
Slide 15
Slide 16
Slide 17
Dilatation amp Effacement
Care of Laboring Patient Early Labor
Care of Laboring Patient Active Labor
Stages of Labor Second Stage
Slide 22
Head Rotation during Descent
Slide 24
Stages of Labor Third Stage
Critical Thinking (2)
Chapter 23 Intrapartal Nursing Assessment
Initial Intrapartum Assessment Pages 608-612
Intrauterine Fetal Resuscitation
Slide 30
Experiences of Pain
Comfort and Pain Relief
Comfort and Pain Relief (2)
Systemic Analgesia Table 25-3 pg 690
Regional Anesthesia
Slide 36
Medication for Pain Relief Birth
Local anesthesia for Episiotomy
Childbirth at Risk (Ch 26)
Critical Thinking (3)
Precipitous Labor amp Birth
Postterm Pregnancy
Malpresentations
Malpresentations (cont)
External Version
MacrosomiaShoulder Dystocia
Slide 47
McRoberts Maneuvers Video
Multiple Gestation
Multiple Gestation (cont)
Abruptio Placentae
Slide 52
Abruptio Placentae (cont)
Placenta Previa
Slide 55
Prolapsed Cord
Prolapsed Cord (2)
Birth Related Procedures Chapter 27
Methods of Induction
Indications for induction of labor
Contraindications to Induction
Cervical Ripening Assessment
Oxytocin Induction pg 767
When to Discontinue Oxytocin
Operative Assisted Deliveries
Slide 66
Cesarean Birth Indications for
Cesarean Birth (cont)
Slide 69
Cesarean Birth
Post-Op Care
Critical Thinking (4)
POSTPARTUM CARE
Slide 74
Postpartum Psychological Adaptations Reva Rubin
Maternal Responses to Newborn Reva Rubin
Blues vs Dpression
Endocrine Adaptations
Physiological Adaptations
Slide 80
Fundal Assessment
Slide 82
Lochia
Lochia Assessment
Lochia Assessment (2)
Cervix amp Vagina
Perineum
Episiotomy
Other Assessments
Thrombophlebitis
Urinary Retention
Vital Signs
Breast Assessment
Lactation
Discharge Instructions
Postpartum Complications
Hemorrhage
Hemorrhage (cont)
Hematomas
Postpartum Infection
Postpartum Infection (2)
Endometritis
Postpartum Infection (3)
Slide 104
Slide 105
Slide 107
Slide 108
Slide 109
Slide 110
Breastfeeding
Postpartum Infection
Nursing Interventions amp Discharge Teachingndash Strict handwashing amp instruction for pt amp familyndash Instruct re proper perineal care
Wiping front to back washing after voiding defecating changing peripads frequently
ndash Well-balanced diet with adequate protein calories vitamin C and fluids (2000 mLday)
ndash Encourage sitz baths early ambulationndash Monitor vital signs and report ss of infectionndash Assess pain and administer analgesicsndash Promote rest relaxation bonding with infant if
separated
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Chapter 22--Processes amp Stages of Labor and Birth
Critical Factors In Labor
Passenger
Slide 4
Slide 5
Fetal Lie and Presentation
Slide 7
Passenger (2)
Powers
Onset of labor
False vs True Labor Contractions
False vs True Labor Cervix
Critical Thinking
Stages of Labor First Stage
Slide 15
Slide 16
Slide 17
Dilatation amp Effacement
Care of Laboring Patient Early Labor
Care of Laboring Patient Active Labor
Stages of Labor Second Stage
Slide 22
Head Rotation during Descent
Slide 24
Stages of Labor Third Stage
Critical Thinking (2)
Chapter 23 Intrapartal Nursing Assessment
Initial Intrapartum Assessment Pages 608-612
Intrauterine Fetal Resuscitation
Slide 30
Experiences of Pain
Comfort and Pain Relief
Comfort and Pain Relief (2)
Systemic Analgesia Table 25-3 pg 690
Regional Anesthesia
Slide 36
Medication for Pain Relief Birth
Local anesthesia for Episiotomy
Childbirth at Risk (Ch 26)
Critical Thinking (3)
Precipitous Labor amp Birth
Postterm Pregnancy
Malpresentations
Malpresentations (cont)
External Version
MacrosomiaShoulder Dystocia
Slide 47
McRoberts Maneuvers Video
Multiple Gestation
Multiple Gestation (cont)
Abruptio Placentae
Slide 52
Abruptio Placentae (cont)
Placenta Previa
Slide 55
Prolapsed Cord
Prolapsed Cord (2)
Birth Related Procedures Chapter 27
Methods of Induction
Indications for induction of labor
Contraindications to Induction
Cervical Ripening Assessment
Oxytocin Induction pg 767
When to Discontinue Oxytocin
Operative Assisted Deliveries
Slide 66
Cesarean Birth Indications for
Cesarean Birth (cont)
Slide 69
Cesarean Birth
Post-Op Care
Critical Thinking (4)
POSTPARTUM CARE
Slide 74
Postpartum Psychological Adaptations Reva Rubin
Maternal Responses to Newborn Reva Rubin
Blues vs Dpression
Endocrine Adaptations
Physiological Adaptations
Slide 80
Fundal Assessment
Slide 82
Lochia
Lochia Assessment
Lochia Assessment (2)
Cervix amp Vagina
Perineum
Episiotomy
Other Assessments
Thrombophlebitis
Urinary Retention
Vital Signs
Breast Assessment
Lactation
Discharge Instructions
Postpartum Complications
Hemorrhage
Hemorrhage (cont)
Hematomas
Postpartum Infection
Postpartum Infection (2)
Endometritis
Postpartum Infection (3)
Slide 104
Slide 105
Slide 107
Slide 108
Slide 109
Slide 110
Breastfeeding
Post op CSection Complications
1Paralytic Ileus
2 Wound Dehiscence
3Wound infection
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Chapter 22--Processes amp Stages of Labor and Birth
Critical Factors In Labor
Passenger
Slide 4
Slide 5
Fetal Lie and Presentation
Slide 7
Passenger (2)
Powers
Onset of labor
False vs True Labor Contractions
False vs True Labor Cervix
Critical Thinking
Stages of Labor First Stage
Slide 15
Slide 16
Slide 17
Dilatation amp Effacement
Care of Laboring Patient Early Labor
Care of Laboring Patient Active Labor
Stages of Labor Second Stage
Slide 22
Head Rotation during Descent
Slide 24
Stages of Labor Third Stage
Critical Thinking (2)
Chapter 23 Intrapartal Nursing Assessment
Initial Intrapartum Assessment Pages 608-612
Intrauterine Fetal Resuscitation
Slide 30
Experiences of Pain
Comfort and Pain Relief
Comfort and Pain Relief (2)
Systemic Analgesia Table 25-3 pg 690
Regional Anesthesia
Slide 36
Medication for Pain Relief Birth
Local anesthesia for Episiotomy
Childbirth at Risk (Ch 26)
Critical Thinking (3)
Precipitous Labor amp Birth
Postterm Pregnancy
Malpresentations
Malpresentations (cont)
External Version
MacrosomiaShoulder Dystocia
Slide 47
McRoberts Maneuvers Video
Multiple Gestation
Multiple Gestation (cont)
Abruptio Placentae
Slide 52
Abruptio Placentae (cont)
Placenta Previa
Slide 55
Prolapsed Cord
Prolapsed Cord (2)
Birth Related Procedures Chapter 27
Methods of Induction
Indications for induction of labor
Contraindications to Induction
Cervical Ripening Assessment
Oxytocin Induction pg 767
When to Discontinue Oxytocin
Operative Assisted Deliveries
Slide 66
Cesarean Birth Indications for
Cesarean Birth (cont)
Slide 69
Cesarean Birth
Post-Op Care
Critical Thinking (4)
POSTPARTUM CARE
Slide 74
Postpartum Psychological Adaptations Reva Rubin
Maternal Responses to Newborn Reva Rubin
Blues vs Dpression
Endocrine Adaptations
Physiological Adaptations
Slide 80
Fundal Assessment
Slide 82
Lochia
Lochia Assessment
Lochia Assessment (2)
Cervix amp Vagina
Perineum
Episiotomy
Other Assessments
Thrombophlebitis
Urinary Retention
Vital Signs
Breast Assessment
Lactation
Discharge Instructions
Postpartum Complications
Hemorrhage
Hemorrhage (cont)
Hematomas
Postpartum Infection
Postpartum Infection (2)
Endometritis
Postpartum Infection (3)
Slide 104
Slide 105
Slide 107
Slide 108
Slide 109
Slide 110
Breastfeeding
1 A mother is experiencing shaking chills during the hour following birth What is the nursersquos initial action
A Take a rectal temperatureB Notify the physician or nurse-midwifeC Cover the woman with warmed blanketsD Review the order sheet for antibiotic orders
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Chapter 22--Processes amp Stages of Labor and Birth
Critical Factors In Labor
Passenger
Slide 4
Slide 5
Fetal Lie and Presentation
Slide 7
Passenger (2)
Powers
Onset of labor
False vs True Labor Contractions
False vs True Labor Cervix
Critical Thinking
Stages of Labor First Stage
Slide 15
Slide 16
Slide 17
Dilatation amp Effacement
Care of Laboring Patient Early Labor
Care of Laboring Patient Active Labor
Stages of Labor Second Stage
Slide 22
Head Rotation during Descent
Slide 24
Stages of Labor Third Stage
Critical Thinking (2)
Chapter 23 Intrapartal Nursing Assessment
Initial Intrapartum Assessment Pages 608-612
Intrauterine Fetal Resuscitation
Slide 30
Experiences of Pain
Comfort and Pain Relief
Comfort and Pain Relief (2)
Systemic Analgesia Table 25-3 pg 690
Regional Anesthesia
Slide 36
Medication for Pain Relief Birth
Local anesthesia for Episiotomy
Childbirth at Risk (Ch 26)
Critical Thinking (3)
Precipitous Labor amp Birth
Postterm Pregnancy
Malpresentations
Malpresentations (cont)
External Version
MacrosomiaShoulder Dystocia
Slide 47
McRoberts Maneuvers Video
Multiple Gestation
Multiple Gestation (cont)
Abruptio Placentae
Slide 52
Abruptio Placentae (cont)
Placenta Previa
Slide 55
Prolapsed Cord
Prolapsed Cord (2)
Birth Related Procedures Chapter 27
Methods of Induction
Indications for induction of labor
Contraindications to Induction
Cervical Ripening Assessment
Oxytocin Induction pg 767
When to Discontinue Oxytocin
Operative Assisted Deliveries
Slide 66
Cesarean Birth Indications for
Cesarean Birth (cont)
Slide 69
Cesarean Birth
Post-Op Care
Critical Thinking (4)
POSTPARTUM CARE
Slide 74
Postpartum Psychological Adaptations Reva Rubin
Maternal Responses to Newborn Reva Rubin
Blues vs Dpression
Endocrine Adaptations
Physiological Adaptations
Slide 80
Fundal Assessment
Slide 82
Lochia
Lochia Assessment
Lochia Assessment (2)
Cervix amp Vagina
Perineum
Episiotomy
Other Assessments
Thrombophlebitis
Urinary Retention
Vital Signs
Breast Assessment
Lactation
Discharge Instructions
Postpartum Complications
Hemorrhage
Hemorrhage (cont)
Hematomas
Postpartum Infection
Postpartum Infection (2)
Endometritis
Postpartum Infection (3)
Slide 104
Slide 105
Slide 107
Slide 108
Slide 109
Slide 110
Breastfeeding
2 The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right What is the appropriate nursing action
A Encourage the client to breastfeed B Assist the client to empty her bladder
C Assist the client to a prone position and place
a small pillow under her abdomen D Massage the fundus
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Chapter 22--Processes amp Stages of Labor and Birth
Critical Factors In Labor
Passenger
Slide 4
Slide 5
Fetal Lie and Presentation
Slide 7
Passenger (2)
Powers
Onset of labor
False vs True Labor Contractions
False vs True Labor Cervix
Critical Thinking
Stages of Labor First Stage
Slide 15
Slide 16
Slide 17
Dilatation amp Effacement
Care of Laboring Patient Early Labor
Care of Laboring Patient Active Labor
Stages of Labor Second Stage
Slide 22
Head Rotation during Descent
Slide 24
Stages of Labor Third Stage
Critical Thinking (2)
Chapter 23 Intrapartal Nursing Assessment
Initial Intrapartum Assessment Pages 608-612
Intrauterine Fetal Resuscitation
Slide 30
Experiences of Pain
Comfort and Pain Relief
Comfort and Pain Relief (2)
Systemic Analgesia Table 25-3 pg 690
Regional Anesthesia
Slide 36
Medication for Pain Relief Birth
Local anesthesia for Episiotomy
Childbirth at Risk (Ch 26)
Critical Thinking (3)
Precipitous Labor amp Birth
Postterm Pregnancy
Malpresentations
Malpresentations (cont)
External Version
MacrosomiaShoulder Dystocia
Slide 47
McRoberts Maneuvers Video
Multiple Gestation
Multiple Gestation (cont)
Abruptio Placentae
Slide 52
Abruptio Placentae (cont)
Placenta Previa
Slide 55
Prolapsed Cord
Prolapsed Cord (2)
Birth Related Procedures Chapter 27
Methods of Induction
Indications for induction of labor
Contraindications to Induction
Cervical Ripening Assessment
Oxytocin Induction pg 767
When to Discontinue Oxytocin
Operative Assisted Deliveries
Slide 66
Cesarean Birth Indications for
Cesarean Birth (cont)
Slide 69
Cesarean Birth
Post-Op Care
Critical Thinking (4)
POSTPARTUM CARE
Slide 74
Postpartum Psychological Adaptations Reva Rubin
Maternal Responses to Newborn Reva Rubin
Blues vs Dpression
Endocrine Adaptations
Physiological Adaptations
Slide 80
Fundal Assessment
Slide 82
Lochia
Lochia Assessment
Lochia Assessment (2)
Cervix amp Vagina
Perineum
Episiotomy
Other Assessments
Thrombophlebitis
Urinary Retention
Vital Signs
Breast Assessment
Lactation
Discharge Instructions
Postpartum Complications
Hemorrhage
Hemorrhage (cont)
Hematomas
Postpartum Infection
Postpartum Infection (2)
Endometritis
Postpartum Infection (3)
Slide 104
Slide 105
Slide 107
Slide 108
Slide 109
Slide 110
Breastfeeding
3 A nurse is caring for a client who is 2 hours postpartum who complains of severe unremitting vaginal pain and inability to void The fundus is firm at the umbilicus with moderate lochia rubra and the perineum appears edematous with significant bruising The nurse suspects the client may have
A A fourth-degree episiotomy B Distended bladder
C Hematoma D Endometritis
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Chapter 22--Processes amp Stages of Labor and Birth
Critical Factors In Labor
Passenger
Slide 4
Slide 5
Fetal Lie and Presentation
Slide 7
Passenger (2)
Powers
Onset of labor
False vs True Labor Contractions
False vs True Labor Cervix
Critical Thinking
Stages of Labor First Stage
Slide 15
Slide 16
Slide 17
Dilatation amp Effacement
Care of Laboring Patient Early Labor
Care of Laboring Patient Active Labor
Stages of Labor Second Stage
Slide 22
Head Rotation during Descent
Slide 24
Stages of Labor Third Stage
Critical Thinking (2)
Chapter 23 Intrapartal Nursing Assessment
Initial Intrapartum Assessment Pages 608-612
Intrauterine Fetal Resuscitation
Slide 30
Experiences of Pain
Comfort and Pain Relief
Comfort and Pain Relief (2)
Systemic Analgesia Table 25-3 pg 690
Regional Anesthesia
Slide 36
Medication for Pain Relief Birth
Local anesthesia for Episiotomy
Childbirth at Risk (Ch 26)
Critical Thinking (3)
Precipitous Labor amp Birth
Postterm Pregnancy
Malpresentations
Malpresentations (cont)
External Version
MacrosomiaShoulder Dystocia
Slide 47
McRoberts Maneuvers Video
Multiple Gestation
Multiple Gestation (cont)
Abruptio Placentae
Slide 52
Abruptio Placentae (cont)
Placenta Previa
Slide 55
Prolapsed Cord
Prolapsed Cord (2)
Birth Related Procedures Chapter 27
Methods of Induction
Indications for induction of labor
Contraindications to Induction
Cervical Ripening Assessment
Oxytocin Induction pg 767
When to Discontinue Oxytocin
Operative Assisted Deliveries
Slide 66
Cesarean Birth Indications for
Cesarean Birth (cont)
Slide 69
Cesarean Birth
Post-Op Care
Critical Thinking (4)
POSTPARTUM CARE
Slide 74
Postpartum Psychological Adaptations Reva Rubin
Maternal Responses to Newborn Reva Rubin
Blues vs Dpression
Endocrine Adaptations
Physiological Adaptations
Slide 80
Fundal Assessment
Slide 82
Lochia
Lochia Assessment
Lochia Assessment (2)
Cervix amp Vagina
Perineum
Episiotomy
Other Assessments
Thrombophlebitis
Urinary Retention
Vital Signs
Breast Assessment
Lactation
Discharge Instructions
Postpartum Complications
Hemorrhage
Hemorrhage (cont)
Hematomas
Postpartum Infection
Postpartum Infection (2)
Endometritis
Postpartum Infection (3)
Slide 104
Slide 105
Slide 107
Slide 108
Slide 109
Slide 110
Breastfeeding
4 A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage What should be the nursersquos correct initial response
A Instruct the client to take her pain medication as prescribed B Notify the physician or nurse-midwife C Instruct the client to increase rest and seek assistance with
household tasks D Instruct the client to call the physician or nurse-midwife if her
temperature reaches 1008
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
Chapter 22--Processes amp Stages of Labor and Birth
Critical Factors In Labor
Passenger
Slide 4
Slide 5
Fetal Lie and Presentation
Slide 7
Passenger (2)
Powers
Onset of labor
False vs True Labor Contractions
False vs True Labor Cervix
Critical Thinking
Stages of Labor First Stage
Slide 15
Slide 16
Slide 17
Dilatation amp Effacement
Care of Laboring Patient Early Labor
Care of Laboring Patient Active Labor
Stages of Labor Second Stage
Slide 22
Head Rotation during Descent
Slide 24
Stages of Labor Third Stage
Critical Thinking (2)
Chapter 23 Intrapartal Nursing Assessment
Initial Intrapartum Assessment Pages 608-612
Intrauterine Fetal Resuscitation
Slide 30
Experiences of Pain
Comfort and Pain Relief
Comfort and Pain Relief (2)
Systemic Analgesia Table 25-3 pg 690
Regional Anesthesia
Slide 36
Medication for Pain Relief Birth
Local anesthesia for Episiotomy
Childbirth at Risk (Ch 26)
Critical Thinking (3)
Precipitous Labor amp Birth
Postterm Pregnancy
Malpresentations
Malpresentations (cont)
External Version
MacrosomiaShoulder Dystocia
Slide 47
McRoberts Maneuvers Video
Multiple Gestation
Multiple Gestation (cont)
Abruptio Placentae
Slide 52
Abruptio Placentae (cont)
Placenta Previa
Slide 55
Prolapsed Cord
Prolapsed Cord (2)
Birth Related Procedures Chapter 27
Methods of Induction
Indications for induction of labor
Contraindications to Induction
Cervical Ripening Assessment
Oxytocin Induction pg 767
When to Discontinue Oxytocin
Operative Assisted Deliveries
Slide 66
Cesarean Birth Indications for
Cesarean Birth (cont)
Slide 69
Cesarean Birth
Post-Op Care
Critical Thinking (4)
POSTPARTUM CARE
Slide 74
Postpartum Psychological Adaptations Reva Rubin
Maternal Responses to Newborn Reva Rubin
Blues vs Dpression
Endocrine Adaptations
Physiological Adaptations
Slide 80
Fundal Assessment
Slide 82
Lochia
Lochia Assessment
Lochia Assessment (2)
Cervix amp Vagina
Perineum
Episiotomy
Other Assessments
Thrombophlebitis
Urinary Retention
Vital Signs
Breast Assessment
Lactation
Discharge Instructions
Postpartum Complications
Hemorrhage
Hemorrhage (cont)
Hematomas
Postpartum Infection
Postpartum Infection (2)
Endometritis
Postpartum Infection (3)
Slide 104
Slide 105
Slide 107
Slide 108
Slide 109
Slide 110
Breastfeeding
5 A 6-day postpartum client complains of fatigue and episodes of crying during the past two days Which of the following statements is a correct response by the nurse
A ldquoThis must be very difficult for yourdquo B ldquoThis sounds like postpartum blues It is a normal response to birthrdquo C ldquoYou sound exhausted Try and sleep when the baby sleepsrdquo D ldquoThis sounds like postpartum depression you should
contact your physician or nurse-midwife for a referral to a counselorrdquo
6 A nurse is caring for a client with a superficial thrombophlebitis Which of the following is the most appropriate nursing action
A Administer anticoagulants per orderB Elevate the affected limbC Apply ice packs to the affected limbD Administer antibiotics per order
