2Physical Changes cardiac & respiratory Heart position outputFluid volumeVSRespiratoryPulmonary functionBMRCardiacCardiac output – rises for 48 hours PP brady – 50-60bpm normal by 10 daysFluid volume – diuresis about 3000/d for first few daysVS – temp first day from dehydrationGastrointestinalNormal immediately BMR elevated 1-2 wks –”starved”Gastric motility decreasedBM 2-3 days PPConstipation r/t hemorrhoids, trauma, dehydration, pain, fear, immobility, meds
3Physiological Changes GU & Reproductive System UrinaryGenitaliaInvolution of uterus Decent After pains Lochia Cervix, Vagina, Perineum Return of menses
4Measurement of descent of fundus for the woman with vaginal birth. The fundus is located two finger breadths below the umbilicus.Measurement of descent of fundus for the woman with vaginal birth.
5Involution of the uterus Involution of the uterus. A, Immediately after delivery of the placenta, the fundus is midline and halfway between the symphysis pubis and the umbilicus. B, About 6 to 12 hours after birth, the fundus is at the level of the umbilicus. It then descends one finger breadth (approximately 1 cm) each day.
11Psychosocial Needs Promoting bonding Rubin’s Phases Taking in – wants to be taken care of Taking hold – takes charge Letting go – more realisticp.468
12Post Partum BluesIs normal, mild, transient condition affects 50-70% of womenBegins 3-4 days after childbirth, peaks on the 4-5 day and resolves within 2 wksSymptoms: insomnia, fatigue, tearfulness, mood instability, anxietyNursing care: encouraged to rest, take care of self, discuss feelings, it is self-limitingp. 468
13Cesarean Care TCDB NPO, ice chips usually 12 hrs Ambulate 12 hours Foley D/C after 24 hoursIV until tolerating dietDressing removed 24hoursSutures removed 1 week after deliveryWhen home – rest, good nutrition, mild exercise
14Nursing Care Review teaching info syllabus p. 38-41 Involution – 6-7 weeksDecent of uterus midline and descend 1cm/dLochia – unique healing – no scar rubra 2-3 days - dark red with small clots serosa 4-10 days – pink to brownish alba 1-6 weeks – cream-whiteCervix – never the samePerineum – if episiotomy, takes 3-6 weeks
15Nursing Care - Teaching Bladder – diuresis first 24 hoursStomach – resume exercise after Dr saysMenstruations – 6 weeks, delayed with lactating mothers, STILL ovulateSex – resume after first menstruation, after episiotomy some loose interest for one yearRest, Rest, Rest
16BreastfeedingColostrum is produced during pregnancy and immediately after birth, contains antibodiesReplaced in 2-4 days with milkTeach: clean breast first in shower, proper positioning, release suction with finger, avoid soap on nipples, disposable bra pads, S&S of complications – redness, swelling, fever, tenderness, cracked nipples – (usually mastitis unilateral)
17LATCH: a breastfeeding charting and documentation tool LATCH: a breastfeeding charting and documentation tool. LATCH was created to provide a systematic method for breastfeeding assessment and charting. It can be used to assist the mother in establishing breastfeeding and define areas of needed intervention.LATCH was created to provide a systematic method for breastfeeding assessment and charting.
18ComplicationsHemorrhage – Hgb < 9 requires Tx atony- most common cause is full bladder laceration – bleeding with firm uterus placenta fragments – bleeding returns to rubra or foul odor noted – more common with “Dirty Dunkin”Infection – Temp above F urinary mastitisThrombophlebitis – pain and redness, +Homan – send for venous scan pulmonary embolism – sudden onset chest pain, SOB
19Post Partum Hemorrhage Loss of blood more than 500 cc – vaginal birth, C/S 1000 cc lostMost common cause – uterine atony others are retained placenta fragments, or infection, hematoma, lacerationsTx – initial is fundal massageS & S – saturate more than one pad/hr, “boggy” uterus, increased lochia with clots, severe perineal pain (with hematoma), tachycardia, hypotension
20Manual compression of the uterus and massage with the abdominal hand usually will effectively control hemorrhage from uterine atony.
21Manual removal of placenta. Performed only by the medical clinician. The fingers are alternately abducted, adducted, and advanced until the placenta is completely detached.Manual removal of placenta. Performed only by the medical clinician.
22Nursing Care of PP hemorrhage Inspect placenta for missing partsAdminister oxytocicsMaintain IV lineApply ice to perineumKeep bladder emptyMassage fundus if boggyMonitor lochia with amount and typeDischarge teaching: report if return to rubra, fever over 100.4, foul smelling lochia, flu-like symptoms
23Puerperal InfectionFever over after the first 24 hours and lasting 2 days or moreChills, flu-like symptoms, elevated WBC (over 30,000), tachycardiaTypes of infections reproductive tract: back ache, abd pain, foul smelling lochia, purulent discharge wound infection: erythema, warmth, swelling, tenderness, drainage.Puerperal infection is any infection of the reproductive tract that occurs within 28 days after abortion or childbirth. The first symptom is usually a fever.Common sources of PP infection are endometritis , mastitis, episiotomy or incision infection, UTI and respiratory infections.
24Mastitis. Erythema and swelling are present in the upper outer quadrant of the breast. Axillary lymph nodes are enlarged and tender.
25PP Infections UTI: pain, burning, urgency or freq of urine Mastitis – erythema, warmth in breast, flue-like symptomsDiagnosis with culture, vag exam, CBCNursing care: assess VS, lochia, incisions, attend to pain, ensure food and fluid intake, obtain specimens, monitor response to antibiotic.
26Thrombophlebitis Inflammation of vessel wall with thrombus Causes: stasis and hypercoagulabilityTypes: superficial venous thrombus: reddened, warm, swollen deep vein thrombosis: occurs in larger veins, positive Homan’s, painRisk factors: immobility, C/S, PIH, DM, smoking, over 40 yr, multiparity, anemiaPrevent: early ambulation and hydration
27Nursing Care Thrombophlebitis Bedrest with leg elevatedChange positions frequently, not flexed kneesTeach no to rub areaDaily measurements of calf and thighSupport stockings, moist heat applicationAssess for complication: embolism, S&S of pulmonary embolism
28Rh IncompatibilityAntibodies cross placenta and attach to fetal red blood cells destroying them
29Rh Incompatibility Mother Rh- negative and fetus Rh positive If Rh positive blood enters system of Rh negative mother reacts by developing antibodies to destroy RBCs with Rh positive antigensBlood may mix during third stage of laborFirst child not effected
30p. 693About 15% of white population in US is Rh negative. – lower in African americans and AsiansRh isoimmunization sequence. Rh-positive father and Rh-negative mother.
31As the placenta separates, the mother is further exposed to the Rh-positive blood.
32Anti-Rh-positive antibodies (triangles) are formed. The body acts as it would any foreign body and develops antibodies to destroy the invading antigen.Most exposure occurs during the third stage of labor. The first child is not affected. Next pregnancy will cross the placental barrier and destroy fetal blood cells. As fetal blood cells are destroyed, fetal bilirubin levels increase which lead to neurological disease. The fetus is anemic it is termed Erythroblastosis fetalis.We will discuss RhoGam in PharmAnti-Rh-positive antibodies (triangles) are formed.
33In subsequent pregnancies with an Rh-positive fetus, Rh-positive red blood cells are attacked by the anti-Rh-positive maternal antibodies, causing hemolysis of the red blood cells in the fetus.
34RhoGAMRho (D) immune globulin suppresses the stimulation of active immunity by Rh-positive foreign RBCGiven IM at 28 weeks antepartum and within 72 hours of delivery – 1 vialBefore 13 weeks give ½ dose after amniocentesis, miscarriage, ectopic pregnancy
35Before Administration Never administer intravenouslyNever administer to a neonateNever administer to an Rh negative patient who has been previously sensitized to the Rh antigenConfirm that the mother is Rh negativeConfirm infant is Rh positive and assess direct coombs testMother has indirect coombs test to determine the presence of antibodies against fetal blood. If the test is positive, amniocenteses may be performed to determine the fetal Rh factor and degrees of hyperbilirubinemia. When infants are jaundiced the infants blood type and a direct coombs test are performed on eh cord blood A positive coombs test indicates that antibodies from the mother have attached to the infants RBC. Bilirubin levels are followed closely for changes that indicate that treatment should be initiated or changed,
36Coombs TestIndirect coombs test on mother to determine the presence of antibodies against fetal blood.If the test is positive, amniocenteses may be performed to determine the fetal Rh factor and degrees of hyperbilirubinemia.Direct coombs test is performed on the cord blood. Positive coombs test indicates that antibodies from the mother have attached to the infants RBC. Bilirubin levels are followed closely for changes that indicate that treatment should be initiated or changed.
37Postpartum Depression/Psychosis Postpartum depression % - all ethnic groups affected.Cause unknown, may be r/t hormonal, exhaustion, anger, chronic stressS&S: starts first 4 wks and last several months, fatigue, loss of self, suicide thoughts cryingTX: combination of psychotherapy, social, medsPostpartum psychosis- rare, bipolar disorder or major depression, frightening thoughts, delusions of dead baby and hallucinations, need psychiatric Tx, will not resolve itself
38Infant Care Cord care Diapering feeding Stools Urine Baths How to take temp