1. Chapter 22--Processes & Stages of Labor and Birth

2. Critical Factors In Labor
The Four P’s: passage, passenger, powers & psyche
Passage:
adequate pelvis?
cephalopelvic disproportion (CPD)
Suspect if presenting part does not engage in pelvis (0 station)

3. Passenger The fetus: head is largest diameter
Fetal head: 4 bones with 3 membranous interspaces (sutures) that allow bones to move & overlap to diminish size of skull
Molding: head becomes narrower, longer, sutures can overlap--normal--resolves 1-2 days after birth
Fontanelles: at junctures of skull bones

5. Fetal Attitude

6. Fetal Lie and Presentation
Leopold's maneuvers/US
Longitudinal lie: Vertical
Presenting part:
cephalic (head),
vertex (occiput), chin (mentum)
breech (buttocks or feet) (c-section)
sacrum
Transverse lie: Horizontal
(c-section)
Presenting part: shoulder (acromion)

7. mom’s pelvis is divided into 4 quadrants: RA, RP, LA, LP
Fetal position:
mom’s pelvis is divided into 4 quadrants: RA, RP, LA, LP
determine which quadrant presenting part (occiput) is pointing towards

8. Passenger
Occiput Anterior (LOA & ROA): most common positions & easiest for birth
Occiput Posterior (LOP & ROP):
can prolong both 1st & 2nd stage of labor
back pain during UCs (back labor)
Instruct partner in sacral pressure during UC’s
Try “all fours,” knee-chest, or alternate side-lying positions to encourage baby to rotate to anterior position

9. Psyche Powers Contractions: supplied by fundus of uterus
Involuntary, become stronger as labor progresses
Abdominal muscles: “pushing” by mom
(2nd stage)
Psyche
Psychological state & feelings of mom
Coping skills
Anxiety, fear, stress
Labor support

10. Onset of labor Usually begins between 38 & 42 weeks
Mechanism is unknown
Upper uterus contracts downward pushing presenting part on cervix causing effacement and dilatation
Premonitory signs of labor:
Lightening, Braxton-Hicks contractions (false labor),
cervical changes (ripening),
bloody show (mucous plug),
rupture of membranes (ROM),
sudden burst of energy

11. False vs True Labor: Contractions
False Labor
Benign and irregular contractions
Felt first abdominally and remain confined to the abdomen and groin
Often disappear with ambulation and sleep.
Do not increase in duration, frequency or intensity
True Labor:
Begin irregularly but become regular and predictable
Felt first in lower back and sweep around to the abdomen in a wave
Continue no matter what the women’s level of activity
Increase in duration, frequency, and intensity

12. False vs True Labor: Cervix
False Labor
No significant change in dilation or effacement
No significant bloody show
Fetus- presenting part is not engaged in pelvis
True Labor
Progressive change in dilation and effacement
Bloody show
Presenting part engages in pelvis

13. Critical Thinking
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 Leopold's maneuvers
E. Determine gestational age of fetus

14. Stages of Labor: First Stage
0 to 10 cm: dilatation--opening of cervix)
Latent: slowest part of the process--slow dilation, mild contractions
from onset of regular UCs to rapid dilatation (about 3-4 cms)
Active: labor “picks up steam”--period of more rapid dilation
from 4 cm to full dilatation: stronger UCs
Transition: cm--intense, N/V, shaking

15. Station Effacement Descent of fetal head (in cm) Thinning of cervix

16. Descent of
fetal head:
Station
Floating
Engaged
At outlet/crowning

18. Dilatation & Effacement

19. Care of Laboring Patient Early Labor
Couple excited, talkative, pain is manageable
Educate regarding labor
Encourage comfort, position changes, bladder emptying
Assess pain, pain tolerance, preferred type of labor/delivery
Reassure regarding what is normal, reduce anxiety
Initial physical assessment & history
Admission--rapport
Fetal & UC monitoring
Vaginal exams, q 2 hours
Vital signs
Temperature q 4 hours-intact or q 2 hours ROM

20. Care of Laboring Patient Active Labor
Couple quieter, discouraged, pain increasing
Transition (7-10 cm): Yikes! “out of control”, shaking, nausea/vomiting, sweating, pain is intense
Prepare for delivery
Second stage (Pushing):
Educate/instruct regarding pushing
Assess urge to push and fetal descent
Encourage/motivate patient, assess fatigue
Monitor fetal/maternal response to pushing bulge, crowning
Signs of imminent birth: perineal bulging

21. Stages of Labor: Second Stage
Pushing & descent of baby (STATION)
Full dilatation (10 cm) to birth
Important NOT to push until full dilation
Assessment: Urge to push? Rectal pressure?
Push only with UC’s
Crowning: baby’s head is visible at the opening of vagina
Cardinal movements of labor youtube.com/watch?v=Xath6kOf0NE&feature=related youtube.com/watch?v=duPxBXN4qMg&feature=related

22. Mechanisms of labor. A, B, Descent. C, Internal rotation. D, Extension
Mechanisms of labor. A, B, Descent. C, Internal rotation. D, Extension. E, External rotation.

23. Head Rotation during Descent

24. Crowning
Crowning
In the hospital
Alternative settings

25. Stages of Labor: Third Stage
Placental stage: from birth to delivery of placenta
Placental separation from uterine wall (rise of fundus, sudden gush of blood, lengthening of umbilical cord)
Entire lining of uterus shed
Expulsion of placenta
Normal blood loss: mL
If placenta does not deliver spontaneously, can be delivered manually
Pitocin infusion started immediately post delivery of placenta

26. Critical Thinking
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?
A) Active
B) Transition
C) Latent
D) Second

27. Chapter 23 Intrapartal Nursing Assessment

28. Initial Intrapartum Assessment Pages 608-612
Vital signs
Fetal heart rate pattern, fetal distress
Contraction pattern, intensity, pain
Membrane status--intact, ruptured, nitrizine test, amniotic fluid: clear, meconium, foul odor
Prenatal records, history of pregnancy, complications, previous pregnancies and deliveries, maternal health problems
Psychosocial/family/cultural issues
Labs: CBC, dip urine for protein, glucose, ketones
Vaginal Exam--effacement/dilation/station, fetal presentation/lie. Assesses LABOR PROGRESS

29. Intrauterine Fetal Resuscitation
*Stop pitocin
Reposition to left lateral, Trendelenberg if needed
Oxygen via mask at 8-10 L/min
Increase IV fluids
SQ terbutaline (0.25 mg) if uterus not relaxing
Vaginal exam for possible cause: prolapse, fetal descent, rupture, abruption
Amnioinfusion for variable decels
Notify MD/midwife

30. B A Which strip shows signs that Immediate intervention is needed?
Why?
What would you do? B A

31. Experiences of Pain Etiology Physiology Perception Factors influencing
Anxiety Psychological factors
Expectations Cultural factors
Support Fetal position

32. Comfort and Pain Relief
Support from doula or coach
Alternative therapies
Relaxation/massage
Focusing and imagery
Breathing
Herbal preparations/aromatherapy
Hypnosis

33. Comfort and Pain Relief
Pharmacological Measures
Narcotic analgesics
Nubain/Stadol/Demerol (pg. 689)
Regional nerve blocks
Epidural/spinal
Local anesthetic blocks
Pudendal/perineal

34. Systemic Analgesia Table 25-3, pg 690
Pre-medication Assessment:
Pain level, VS, allergies, drug dependence (withdrawal), vaginal exam/progress in labor, UC pattern, fetal heart rate tracing
Post-medication Assessment:
VS, esp. RR, LOC, dizziness (bedpan), sedation, FHR
Reversal agent: Naloxone (Narcan)
Competes with narcotic for opiate receptors. Used in both mom and baby. (avoid with narcotic dependence)

35. Regional Anesthesia
Injection of local anesthesia to block specific nerve pathways
Epidural/spinal anesthesia
Systemic toxicity: cardiovascular collapse
Side effects: Hypotension (preload with IV fluids), fetal distress on FHR tracing, spinal HA
Contradindications: coagulation disorders, low platelet count (< 100), allergy, neurologic disease, aspirin use
Nursing care: Preload IV fluids (LR), monitor BP, HR, anesthesia level, FHR, foley cath, maternal positioning

36. Epidural Anesthesia

37. Medication for Pain Relief: Birth
Local anesthesia
Pudendal nerve block (2nd stage, episiotomy, repair)
Local infiltration in perineum (episiotomy, repair)
General anesthesia
Regional contraindicated/emergency
Preparation: hip wedge, preoxygenation, cricoid pressure for intubation
Complications: fetal depression, aspiration of vomitus (Bicitra)

38. Local anesthesia for Episiotomy

39. Childbirth at Risk (Ch. 26)
Complications of Labor or Delivery

40. Critical Thinking
The client in active labor is requesting pain relief. The physician orders epidural anesthesia for the client.
Which of the following parameters should the nurse be prepared to assess immediately after administration of the epidural?
A) For headache.
B) For urinary retention.
C) The blood pressure.
D) The maternal pulse rate.

41. Precipitous Labor & Birth
Labor in < 3 hours
Risk factors:
Multiparity, oxytocin or amniotomy,
hx of precipitate labor
Risks for injury
Maternal: cervical, vaginal & perineal lacerations with possible hemorrhage, pain, anxiety
Fetal: Birth trauma (intracranial bleed, brachial palsy), meconium-stained fluid, fetal distress
Management: close monitoring for cervical changes, induction

42. Postterm Pregnancy > 42 weeks
Maternal risks: trauma/hemorrhage due to larger baby, ↑operative delivery/c-section
Fetal risks: placental changes that ↓oxygenation to baby and ↑mortality rate, oligohydramnios (↑cord compression during labor), LGA baby (↑birth trauma, shoulder dystocia), meconium aspiration
Management: > 40 wks, NST, BPP or modified BPP (NST & AFI), induction

43. Malpresentations Occiput-posterior (OP)
Prolonged labor, back labor (sacral nerve compression), arrested dilatation/ descent, perineal tears
Usually vaginal, but may need C-Section if baby doesn’t rotate
Management: positioning (side-lying, knee-chest or hand-knees), sacral pressure during UC’s
Transverse Lie
Associated with: pendulous abdomen, uterine masses/fibroids, congenital abnormalities of uterus, hydramnios
Attempt External Cephalic Version, if unsuccessful obligatory C-section

44. Malpresentations (cont)
Breech presentation
Assessment: FHT heard high on the abdomen, Leopold’s,
vaginal exam & US.
Higher risk of anoxia from prolapsed cord, traumatic injury to the after coming head,
fracture of spine or arm,
dysfunctional labor
Usually delivered by
C-section

45. External Version
External cephalic version (37-38 wks): abdominal manipulation to change fetal presentation
Contraindications: multiple gestation, fetal breech is engaged in pelvis, oligohydramnios, nonreactive NST, nuchal cord, vaginal bleeding, IUGR, ROM.
Risks: immediate cesarean birth
Nursing actions: NPO 8 hrs, NST, IV line, terbutaline, continuous FHR, US used to guide manipulations, assess for: labor, fetal distress. O- moms need Rhogam following the procedure

46. Macrosomia/Shoulder Dystocia
Wt. > 4500 gms (9-10 lbs)
Associated with:
DM, Gestational DM, Multiparity, Postdates, obesity
Risks:
Shoulder dystocia, difficulty delivering the shoulders after head is delivered (obstetrical emergency)
Maternal: vaginal/cervical tears, pp hemorrhage, rupture
Fetal: compressed cord, fractured clavical, asphyxia & neurologic damage, brachial plexus injury (Erb’sPalsy)
S/S: Turtle sign
Nursing interventions: McRoberts maneuvers, suprapubic pressure. PP: assess for uterine atony/hemorrhage; trauma, cerebral or neurologic damage to baby

47. Video: youtube.com/watch?v=jV6g427UMxY&feature=related

48. McRoberts Maneuvers Video

49. Multiple Gestation
Monozygotic (identical) twins: can have 1 or 2 placentas, chorions, or amnions (↑risk if all shared)
Dizygotic (fraternal) twins: 2 of everything.
Dx: faster than usual growth of uterus, ↑AFP, HCG, Ultrasound
Risks:
Maternal: SAB, gestational DM, HTN/preeclampsia/HELLP, hydramnios, PT labor & delivery
Fetal: Preterm birth, twin-to-twin transfusion

50. Multiple Gestation (cont)
Management:
US to determine what type of twins
Prevention of PT labor/routine cervical measurements (US)
NST surveillance
Birth: depends on maternal & fetal complications and fetal position/ presentation
Examination of placenta
Close monitoring PP for hemorrhage (atony)

51. Abruptio Placentae Premature separation of placenta from uterine wall
S/S: sharp, stabbing pain high in fundus, heavy bleeding (may be occult), hard, board-like uterus, tense, painful uterus, signs of shock due to blood loss, Port-Wine aminotic fluid if ROM.
Predisposing fx: ↑parity, adv. maternal age, short umbilical cord, chronic HTN, PIH, direct trauma, vasoconstriction from cocaine or cigarette use
Fetal distress on monitor. Can progress to DIC.

53. Abruptio Placentae (cont)
Management:
Emergency. Immediate c-section if birth not imminent.
Lg. gauge IV
O2 via mask, fetal monitoring, maternal VS, lateral positioning, labs, blood transfusion (have 2 units avail)
CBC (H&H), Fibrinogen levels, platelet count, PT/PTT, fibrin degradation products ( sx of DIC)

54. Placenta Previa NEVER do vaginal exam !!!
Low implantation of placenta (1 in 200)
abrupt, painless, bright red bleeding
Associated with ↑parity, adv. maternal age, previous c-section or uterine curettage, multiple gestation
Dx: ultrasound. May resolve as pregnancy progresses.
Bleeding common around 30 wks: Bedrest, VS, IV fluids, type & cross-match,
observe for bleeding
Emergency: assess bleeding, hx, uc’s/labor,
NEVER do vaginal exam !!!
C-Section delivery, possibly before 37 wks. Steroids for mom. Watch for pp hemorrhage.
Table 26-6, pg 746, differential dx: abruptio/previa

55. Placenta Previas
Low-lying
Marginal
Complete
Partial

56. Prolapsed Cord
Loop of umbilical cord slips down in front of the presenting part
S/S: deceleration of FHT: bradycardia, persistent variable decels, cord palpatedor seen in vagina
Associated with:
Premature rupture of membranes
Transverse or breech presentation
Multiple gestation
Placenta previa
Hydramnios
CPD (non-engagement of fetal head)

57. Prolapsed Cord
Management: Hold fetal head off cord, Trendelenburg or knee/chest position, immediate emergency c-section
Prevention
Watch fetal heart tones after rupture of membranes (SROM or AROM). Do VE if any sign of fetal distress.
If head not engaged, women with ruptured membranes should not ambulate.

58. Birth Related Procedures Chapter 27
Induction of labor
The deliberate initiation of uterine contractions, by chemical or mechanical means, to stimulate labor and birth before spontaneous onset of labor
Primary agent of induction: Pitocin by IV
Pitocin is also used to augment labor
If cervix not “ripe”, may need a preparatory stage of cervical ripening before pitocin can be started → Cervidil

59. Methods of Induction
Prostaglandins (Cervidil, prostin gel, Prepidil, Cytotec) applied intravaginally for cervical ripening
Pitocin (oxytocin) by IV
Amniotomy or stripping of membranes
Sexual intercourse
Nipple stimulation
Herbal preparations

60. Indications for induction of labor
Post-term pregnancy (≥ 42 weeks)
Premature or prolonged rupture of membranes
Maternal complications (Rh isoimmunization, Diabetes, Pulmonary disease, Pregnancy-induced hypertension)
Chorioamnionitis
Suspected fetal problems- Intrauterine Growth restriction (IUGR) and hydrops (fetal hemolytic disorder as result of Rh isoimmunization when maternal immune system attacks fetal red blood cells)
Fetal demise

61. Contraindications to Induction
previous c-section
placenta previa or abruption
prolapsed cord
fetal bradycardia, nonreassuring fetal status
vaginal bleeding of unknown cause
cephalopelvic disproportion
active genital herpes

62. Cervical Ripening Assessment
Bishop Score- rating that determines if the cervix is ready for induction--Pg. 765
Fetus must be in vertex position
Baseline data on fetal and maternal well-being (at least half an hour of monitoring)
Fetal monitoring and uterine contraction monitoring is imperative
Notify MD if hyperstimulation or fetal heart rate distress is noted

63. Oxytocin Induction pg 767
Confirmation that the baby is in a cephalic (vertex) position (head down)
V/S done at least every 30 minutes and when dose is titrated
FHTs and UCs assessed every 30 minutes
Titration of oxytocin till UCs every 2-3 minutes
Cervical dilation should be 2 cm/hr (ideally)
Reassuring FHTs between beats/min

64. When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2 minutes apart
-Now being called tachysystole
-Inadequate uterine relaxation between contractions
<60 sec between UC’s
Fetal Distress -any decelerations or decreased baseline variability

65. Operative Assisted Deliveries
Forceps
Indications: unable to push, arrested descent, need a quick delivery, breech
Associated with: maternal/fetal birth trauma, rectal sphincter tear, urinary stress incontinence
Vacuum extraction
Advantages: fewer lacerations, less anesthesia needed,
Disadvantages: marked caput, cephalhematomas, scalp laceration/bruising

67. Cesarean Birth Indications for:
Maternal Factors
Active genital herpes
AIDS/HIV +
Cephalopelvic disproportion
Severe preeclampsia, diabetes
Obstructive tumor
Ruptured uterus
Previous c-section
Failed induction/fx to progress in labor
Elective?
Placenta Factors
Placenta previa
Placental abruption
Umbilical cord prolapse
Fetal Factors
Breech, transverse lie
Macrosomia
Extreme low birth wt
Fetal distress
Fetal anomalies
Multiple gestation

68. Cesarean Birth (cont) Mortality/morbidity Maternal Complications
4 x higher than vaginal birth in US. Most risk assoc. with emergency c-section
Incision
Skin vs. uterine
Classical vs low transverse
Maternal Complications
Infection
Anesthesia reactions
DeepVeinThrombophebitis
Bleeding
Ureteral/bladder injury
Increase risk for subsequent pregnancy
Placenta Acreta/Previa, Infertility

70. Cesarean Birth Pre-op: CBC w/ platelets, hold clot, bicitra/antacid
monitor baby
Teaching: pre & post-op, anesthesia, recovery, breastfeeding
Psychosocial issues:
Fear
Self-image/self-esteem

71. Post-Op Care Assess fundus/bleeding, vital signs, DVT. Antibiotics.
Pain: Duramorph. Breakthrough pain meds. Benadryl for itching. Zofran for nausea.
Clear liquids and advance as tolerated.
Assess for GI function. Bowel sounds? Passing flatus?
Ambulation. Pre-medicate, teach splinting with pillow.
Stool softener

72. Critical Thinking
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.

73. POSTPARTUM CARE

75. Postpartum Psychological Adaptations Reva Rubin
Taking in: Mom wants to talk about her experience of labor & birth, preoccupied with her own needs
Taking hold: More ready to resume control of her body, baby & 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 & breast-feeding (within 1/2 hr of birth is best).

76. Maternal Responses to Newborn Reva Rubin
Touch- progresses from fingertips → palming →cuddling →
Voice- high-pitched & babies respond
Odor- mom’s respond to baby’s unique smell
Eye contact- en face position
delay eye ointment & bright lights
Nurse role- be able to answer ? About baby

77. Blues vs Dpression  Postpartum/baby blues:  Postpartum Psychosis
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 aren't 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.

78. Endocrine Adaptations
Hormones: drop after delivery of placenta.
hCG & hPL gone by 24 hours
Estrogen & progesterone drop within 1 wk
FSH remains low for 12 days, then rises to begin new cycle
Sex is ok once lochia is alba. Menstrual period in 6-10 wks.
Contraception necessary.

79. Physiological Adaptations
Uterine involution
@ umbilicus first 24 hours--should feel firm
Decreases 1 finger’s breadth per day
By 10th day, no longer palpable
If high (3 or 4 fingers above U) and/or deviated to right, have pt. void
Risk for delayed involution:
Multiples, hydramnios, exhaustion, grand multiparity, excessive analgesia
Afterpains

81. Fundal Assessment Every 10-15 mins in first hour. Supine position
Palpate: one hand at base of uterus & other at umbilicus. Press inward and downward and feel for firm globular mass.
Assess:
Height (fingers above/below umbilicus)
Position (midline, deviated to right or left)
Consistency: firm, soft, boggy
If not firm, massage & should become firm. If still boggy, notify MD/assess for clots, hemorrhage. Administer oxytocin or other oxytocic (methergine, hemabate).

83. Lochia Rubra: Red, day 1-3, blood
Serosa: Pinkish or brownish, day 3-10, blood, mucus, leukocytes
Alba: whitish, day (may last 6 wks), largely mucus & leukocytes
If flow increases, woman should rest more
Warning sign: if lochia returns to previous type (alba to serosa, or serosa to rubra)

84. Lochia Assessment Check q 15 mins in 1st hour. Assessment:
Color (rubra, serosa, alba), amount, odor, presence of clots.
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 pads/day

85. Lochia Assessment Assessing Amounts:
Scant: peripad has stain less than 1 inch in length after 1 hour
Small: stain less than 4 inches after 1 hour mL
Moderate: stain less than 6 inches after 1 hour mL.
Instruct in perineal care: ∆ pad frequently, hand washing, s/s of infection & hemorrhage, no tampons

86. Cervix & 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.
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.

87. Perineum
Assessment: turn pt to side in Sim’s position. Lift upper buttock and assess for:
Ecchymosis, hematoma, erythema, edema, intactness, approximation, drainage or bleeding from stitches
Assess for hemorrhoids & document number, appearance & size

88. Episiotomy Midline or mediolateral Nursing care:
Assess for approximation, swelling, oozing, infection
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

89. Other Assessments
Constipation: Give stool softeners as ordered, prune juice, encourage ambulation, adequate fluid intake, fiber in diet.
Homan’s sign: assess calves for redness, warmth, pain, swelling.
-↑risk of DVT, thrombophlebitis.
-Occur in postpartum because:
Fibrinogin level is elevated
Dilatation of lower extremity veins
Relative inactivity during labor or prolonged time in delivery room stirrups leads to pooling, stasis & clotting of blood in lower extremities.

90. Thrombophlebitis Superficial leg vein disease:
S/s: tenderness in portion of vein, local heat & redness, normal temperature or low-grade fever
Tx: local heat, elevate limb, bed rest, analgesia, elastic support hose
Deep Vein Thrombosis (DVT):
S/s: edema of ankle, leg, initial low-grade fever, then high temperature & chills, tenderness & pain, changes in limb color & difference in circumference
Tx: IV heparin, bed rest, elevation of leg, analgesics, warm moist heat, antibiotics

91. Urinary Retention
Diuresis begins p birth to rid extra fluid ( mL)
Trauma to bladder & 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.

92. Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration. If or above, suspect infection.
Rapid or thready pulse--sign of hemorrhage.
BP: monitor--still at risk of PIH. Methergine (oxytocic) can ↑BP. ↓BP could be sign of hemorrhage.
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.

93. Breast Assessment Breasts
Soft: Soft on palpation, day 1 & 2
Filling: firmer & warmth, day 3
Engorged: appear large, reddened, taut, shiny skin, warm, hard, tense & tender/painful on palpation
Mastitis (infection): only one part of breast is warm/reddened--UNILATERAL
Nipples: look for cracking, fissures, blisters, pain

94. Lactation Engorgement: day 3 or 4. Breast care: If breastfeeding:
Encourage frequent breastfeeding.
Warm compresses or warm shower.
If not breastfeeding:
Cold compresses/ice, snug bra or breast binder, oral analgesics.
Breast care:
Wash daily with water and air dry –NO SOAP
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.

95. Discharge Instructions
Avoid/limit heavy lifting, stairs.
Good diet, increase fluids if breastfeeding.
Adequate rest, exercise/activity as tolerated.
Report fever, foul smelling discharge, increased pain or bleeding to MD.
Sex/contraception.
Follow up in 6 weeks with MD.

96. Postpartum Complications
Postpartum Hemorrhage
CAUSES: Uterine atony, lacerations, retained placental fragments
Risk factors:
↑ uterine distension: multiples, polyhydramnios, macrosomia, fibroids
Trauma: rapid or operative birth
Placental problems: previa, accreta, abruptio, retained placental fragments
Atonic uterus: prolonged pitocin, magnesium sulfate or labor; ↑ maternal age or parity; uterine scar; chorioamnionitis; anemia; prior history
Inadequate blood coagulation: fetal death or DIC

97. Hemorrhage Interventions:
Fundal massage, ensure bladder emptying. If uterus is firm but bleeding persists, suspect laceration.
Administer oxtocics (pitocin, methergine, hemabate, prostaglandins), blood replacement.
Frequent assessment of bleeding, vital signs.
MD: Bimanual massage, manual exploration of uterus, uterine packing,
D & C, hysterectomy.

98. Hemorrhage (cont.) Lacerations: cervical, vaginal, perineal
Retained placental fragments:
can occur well after delivery. Maternal serum test for hCG or US. Possible D&C.
May see symptoms even after 1 week
Subinvolution: retained placenta, infection, fibroids
PO methergine, antibiotic.

99. Hematomas Cause:Trauma during the birth process
Puerperal hematomas occur in 1:300 to 1:1500 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 laceration/incision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva, vaginal/paravaginal 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, H&H
Treatment: evacuation and repair of bleeding source by MD

100. Postpartum Infection Puerperal Infection: Endometritis
infection of reproductive tract within 6 wks of childbirth
Increased risk with:
C-section
Prolonged ROM, chorioamnionitis
Retained placental fragments
Preexisting anemia
Prolonged/difficult birth, instrumental birth
Internal fetal monitoring or IUPC
Uterus explored after birth/manual removal of placenta
Preexisting vaginal infection (BV or chlamydia)

101. Postpartum Infection Endometritis: infection of endometrium
Associated with chorioamnionitis & C-section
S/S: 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.)
Can progress to pelvic cellulitis or peritonitis.

102. Endometritis
TX: antibiotics as determined by culture of lochia; oxytocics such as methergine, if necessary, ↑ fluid intake, pain relief
Nursing considerations: Fowler’s position or walking encourages drainage by gravity, gloves, strict handwashing
Usual course is 7-10 days
May result in tubal scarring & interfere with future fertility

103. Postpartum Infection Nursing Interventions & Discharge Teaching
Strict handwashing & instruction for pt & family
Instruct re proper perineal care
Wiping front to back, washing after voiding/ defecating, changing peripads frequently
Well-balanced diet with adequate protein, calories, vitamin C and fluids (2000 mL/day)
Encourage sitz baths, early ambulation.
Monitor vital signs and report s/s of infection
Assess pain and administer analgesics
Promote rest, relaxation, bonding with infant if separated.

104. Post op C/Section Complications
Paralytic Ileus
Wound Dehiscence
Wound infection

105. A mother is experiencing shaking chills during the hour following birth. What is the nurse’s initial action?
A. Take a rectal temperature
B. Notify the physician or nurse-midwife
C. Cover the woman with warmed blankets
D. Review the order sheet for antibiotic orders

106. 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 \

107. 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.

108. A. Instruct the client to take her pain medication as prescribed
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 nurse’s 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

109. 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. “This must be very difficult for you.”
B. “This sounds like postpartum blues. It is a normal
response to birth.”
C. “You sound exhausted. Try and sleep when the baby
sleeps.”
D. “This sounds like postpartum depression; you should contact your physician or nurse-midwife for a
referral to a counselor.”

110. 6. A nurse is caring for a client with a superficial thrombophlebitis
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 order
B. Elevate the affected limb
C. Apply ice packs to the affected limb
D. Administer antibiotics per order

111. Breastfeeding
(Breastfeeding Basics)
(What’s the Big Deal?)
(latch-on 1)
(latch-on 2)