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OB-PEDS Chapter 15-Reading Notes and Morning lecture dictation-Dermer Caring for the Postpartal Woman and Her

Family Newborns and Mothers Health Protection Act of 1996: Prohibits 3rd party payers fr om restricting benefits for hospital stays for less than 48 hours after a vagina l birth or less than 96 hours after a C-Sect. Protecting the infant from abduction: Mothers should be instructed to release the infant only to properly identified h ospital personnel When 2 or more infants have a similar or same last name, it is common practice f or the infants cribs and charts to indicate the mothers first name, and bear a lab el that designates a NAME ALERT. When there are multiple births, the infants cribs may be labeled with the infants name followed by a letter of the alphabet (A, B, C, D) Maternal Assessment Vital Signs: Vaginal Birth: VS q 15 minutes during the 1st hour after childbirth; then q 30 minutes during the 2nd hour; once during the 3rd hour; and then q 8 hours until discharge or until stable C-Section: q 30 min x 4 hours; then q 1 hour x 3; then q 4-8 hours Temperature: Can elevate up to 100.4 F: r/t exertion and dehydration that accompany labor; in creased fluids return to normal range; also increased breast vascularity may als o cause a transient increase in temp; should be afebrile after the first 24 hour s. Pulse: Heart rates 50-70 bpm common first 6-10 days postpartum; elevated stroke volume r/t decrease in weight leads to decreased heart rate; Postpartal tachycardia may result from a complication, prolonged labor, blood loss, temperature elevation, or infection. Blood Pressure: Compare with 1st trimester; decreased may be assoc. with hemorrhage or decrease in intrapelvic pressure; Increase of 30 systolic or 15 diastolic may be sign of gestational diabetes, esp. when associated with H/As or visual changes Respirations: Should remain within the normal range of 12-20, however, slight elevations may o ccur due to pain, fear, excitement, exertion, or excessive blood loss Abnormal signs that could be indicative of pulmonary edema or emboli , and need to be reported are: tachypnea, abnormal lung sounds, SOB, chest pain, anxiety o r restlessness **Shaking chills during the time immediately after childbirth are normal and res ult from: pressure changes in the abdomen after the reduction in the bulk of th e uterus and temperature readjustments after the diaphoresis of labor.

Fundus, Lochia, and Perineum: Within a few minutes after birth, the firmly contracted uterine fundus should be palpable through the abdominal wall halfway between the umbilicus and the symph ysis pubis; Approx. 1 hour later, the fundus should have risen to the level of t he umbilicus, where it remains for the following 24 hours. Then the fundus descends one fingerbreadth (1 cm) per day in size. *Assess lochia (puerperal discharge of blood, mucus, and tissue) q 15 min during immediate postpartum

*Assess perineum with patient in Sims (side-lying) position with back facing nurs e. Use acronym REEDA and assess for: Redness Edema Ecchymosis Drainage Approximation of the episiotomy if present *Frequent nursing uterine assessments of the fundus is essential for the first p ostpartal hour; Relaxation of the uterus (atony) results in rapid, life-threaten ing blood loss because no permanent thrombi have yet formed at the placental sit e. Hemorrhoids: Use ice packs, topical anesthetic ointments or witch hazel pads; frozen tea peri pads are also helpful Teach: side lying position, sit on flat and hard surfaces and tighten buttocks before sitting. Hemorrhoids developed during pregnancy usually disappear within a few weeks afte r childbirth. POSTPARTUM ASSESSMENT: THE BUBBLE-HE MNEMONIC: B Breasts Inspection of nipples: everted, flat, inver ted? Breast tissue: soft, filling, firm? Temperatu re and color: warm, pink, cool, red streaked? U Uterus Location (midline or deviated to R or L sid e) and tone (firm, firm with massage, boggy) What does Boggy mean? Soft, squishy. What are we going to worry about then? Hemorrhage. How do you assess a uterus? Make sure you always support the lower uterine segment because what happens if you dont? An inversion. What is an inversion? Its when you push the uterus right out. Ex. of doctor pulling on cord too much and p ulled the uterus right out. What do we have to do if a patient has an inversion? Many times the d octor can do a replacement (get the uterus back in place), but if not, must do a hysterectomySo just be very careful when palpating someones uterus. B Bladder Last time the patient emptied her bladder ( spontaneously or via catheter)? Palpable or nonpalpable? Color, odor, and amount of urine? How are we going to assess it? It will be full if it is poking up when palpating O R if it is displaced to the right or left. B Bowels Date/time of last BM; presence of flatus a nd hunger (unless the colon was manipula ted, do not need to auscultate for bowel sounds) What do we want to assess with the bowel? Listen in all 4 quadrants; peristalsis w ill slow down; sometimes they are given Cola ce if constipation is a problem she can also con tinue this treatment at home, especially if she has had an episiotomy; When would you expect them to have absent bowel sounds? If they had anesthesia, especially general anesthesia; Most doctors will st art off with a clear liquid diet.

L ee flow?

Lochia

Color, amount, presence of clots, any fr Type as well as other tissue trauma (laceratio

E (I) Episiotomy ns, etc); assess using REEDA (Incision)

H/L Homans Sign Pain, varicosities, warmth or discoloration in calv es; presence of pedal Legs pulses; sensation and movement (after C-Section) What predisposes a woman who has had a baby to a DVT? You produce more clotting factors when you are pregnant so that you dont bleed to death, but the downside to that is production of DVTs. What do you do if you assess a patient and the Homans sign is present on the right leg, what do you do? Well we know the S/S o f a DVT are that one calf will be larger than the other one, so you might measure the circumference, also redness, tenderness, and warmth on the larger calf. What might could have been going on in labo r that might show a positive Homans Sign? It could be that she had her legs up in s tirrups, and had been pushing for a long time, so it has made her legs sore. So before you call the doctor, make sure you do a good assessment.especially if both sides show a positive sign. Follow the protocol at the hospital! What else do they usually do for C-Sect. pat ients to prevent DVTs? Put on SCUDS, or compr ession booties, or something like this; then get them up to walk as soon as possible. E Emotions Affect, patient-family interaction, effect s of exhaustion; What would be normal emotional wise after a delivery? Baby blues; if a c-section, maybe did not get to follow their ideal birthing plan; Baby blues should last the first week or two.beyond that, it becomes post-partum depression; What are we gonna do about that? Teach that if she has depressive thoughts or feelings, that she needs to call her doctor; When does it progress to psychosis? Thoughts or a plan of how they might try to hurt their child fantasies about it. Be sure to question your patient about their though ts, feelings, encourage to discuss, .most are not apt to discuss these things without you opening the conversation; you have to ask them specifically if they ever have thoughts of harming themselves or the baby. (B) Bonding Interaction with infanttaking in phasepr esence of finger tipping, gazing, enfol ding, calling infant by name, identifying unique characteristics ________________________________________________________________________________ ____ Breasts: First 2 postpartal days, breasts tissue should feel soft to the touch; inspect f or size, shape, tenderness, and color By day 3, breasts should begin to feel firm and warm By day 4 or 5, breastfeeding mothers breasts should feel firm before infant feedi ng, then become soft once the baby is satiated. Nodules could be blocked milk ducts; Nipples need to be assessed for presence of fissures, cracks, blood, or dried milk, and whether they are erect or inverted. Uterus: Involution: uterus returns to its non-pregnant size

________________________________________________________________________________ ____ LECTURE NOTES-DERMER 9/17/12 Note for Chapter 16: In box it says that Cytotec is given IV, but this is NOT C ORRECT! Only vaginal, P.O. or rectally! What is the normal size of a NON pregnant uterus? Size and shape of a pear; alt hough with each pregnancy, it tends to not shrink down to its normal size comple tely. What would be the cause or term for a uterus not shrinking down to its normal si ze? (never answered) What is Hypotonia? Loss of muscle tone. What is a problem with that post-parte m? Hemorrhage. Uterus needs to shrink down or else they have hemorrhage. What does Involution mean? Uterus shrinking back down to its normal size. What is normal rate of involution? Always use the umbilicus as the reference point. If you see a U/2 on a chart, what does that mean? 2 cm below the umbilicus. What if you have a 2/U? 2 cm above the umbilicus. You want the uterus to be in the midline, but what if it is off to one side? A fu ll bladder; just like a full bladder keeps the babys head from progressing down t he birth canal and it also keeps the uterus from contracting so what does that l ead to?? Hemorrhage What is the Priority Nursing diagnosis for any woman in labor?? Potential for h emorrhage; always think about what can kill somebody..Pain does not kill anyone. What is after birth pains? When the uterus is contracting back to its previous state prior to pregnancy. Perfectly normal; why does it not occur with the 1st pregnancy? Because the uterus has not been overstretched as much; How will the patient describe this pain to you? (couldnt hear response) After delivery, what will the lochia look like? Bright Red Rubra; why? And how long does it last? Couple days Then Serosa; mix of blood, vaginal and cervical mucus; pinkish brown color Then Alba; whitish or yellowish color; presence of leukocytes; lasts 6 weeks (?) Lets say our patient has gone through these stages and then after 4 weeks or so s tarts having bright red bleeding again. What will you tell her? What might be going on? Menstrual cycle!! What do we tell patients to report to their doctor? Large clots, foul odor, sev ere cramping What types of things would the patient tell us that indicates she needs to come in and see the doctor? Saturating more than 1 pad an hour; could be impending hemorrhage If doctor wants to be very accurate on how much bleeding is occurring, how do we do that? 1 gram = 1 mL What will we tell this patient to do if she is having bright red bleeding, but n ot really having cramping, or foul odor? Ask if she is breastfeeding? Then as k her to monitor and if gets worse to have her come in.

If patient is breastfeeding, what should we talk to them about? Contraception, because can still be ovulating even without a menstrual cycle. Patient should b e spoken to about contraception before leaving the hospital. How long should a woman wait to have sex after having a baby? 6 weeks, but in r eality, they should be told to wait until the bleeding stops, because as long as they are having bleeding it means that the cervix is dilated just a little bit which may allow infection to take place and the episiotomy may still be healing as well. What about safety issues for mom and baby that might be related to early dischar ge? Vaginal deliveries are now kept for only 24-48 hours at most in hospital; C -Sections for 48 hours; Teach mom NOT to sleep with baby; Caution moms on pain medications and overly ti red not to rock for too long because baby may fall from arms; How long can mom not drive after delivery?? As long as they are on any type of pain meds and 2 weeks What about with a C-Section? Until they follow up with their doctor, but again if on pain meds, no driving. What else can a mom with a C-section not be able t o do when driving? Use abdominal muscles to get to the brakes and turn to check other lanes. Moms with C-sections are usually told 4-6 weeks before safely dri ving again. Better to tell them too long, than not long enough. *Be sure to give the patient the reason for not doing these things, or they may tr y to just chance it if they dont understand. *Also be sure to teach about car seat safety and how to use. Never use a car se at that has been in an accident. Infant is placed in back center, rear-facing. What do we tell mom about jaundice? It starts from the head down-cephalocaudic. So if the sternum is yellow, then its pretty bad already; baby needs a few minu tes of sunlight (5-15) per day; Normal amount of diapers to wet per day=at least 6 per day AFTER mothers milk com es in if breastfeeding. What do we do if moms breasts become so engorged that baby cannot latch on? Use warm compresses or express some first. What else do we want to tell mom about if she is NOT breastfeeding? Dont stimula te the breasts; they will become engorged after about day 3; dont take warm showe r; wear a tight bra; ice packs; Tylenol Another safety issue---What are we going to do in a hospital to be sure the baby does not get abducted? VERIFY bracelets by asking mom to read off her bracelet number.NEVER ask mom if h er bracelet number is 55388020! She may be drowsy or under influence of meds, e tc. Safety: we want the babies on their backs or sides, and do NOT want mothers pro pping up bottles! What if the baby has reflux, what might you have to do? Prop up the mattress at the head. When and how do they use a bulb syringe? Squeeze it before you insert in nose o r mouth. Put bulb in corner of mouth to avoid hitting uvula. What kind of assessment are we going to do for mom an hour after delivery when s he is on the floor? The BUBBLE-HE..see on page 1.

What Medications may the doctor may use to prevent post partum hemorrhage? Oxyt ocin 10-20 units in IV fluid, but if they dont have an IV inthen they give IM. **I f it is already in their IV and running, then we just open it up all the way. Lets say we give her the whole 500 ml of fluid with Oxytocin in it and she still continues to bleed, what might the doctor order then? HEMABATE: (look up-she did not go over) Whats another one we might give? Methergine.give IM first, and then after first d ose or two then will order P.O. for the first 6 hours for the first 24-48 hours. What will we tell patients the goal of Methergine is? To contract the uterus, so to expect cramping. When is Metergine contraindicated? HBP What is the other drug we might use? Cytotec-for post-partum hemorrhage given r ectally or P.O. NOT IV! And wont give vaginally for hemorrhage or it will come ou t. How much do we give? 400-1000 mcg. What else do we give Cytotec for? Cervical ripening then give 25 mcg and up to 50 mcg, but start on lower end. Lets say our patient has had a vaginal delivery, what S/S might she show with a he matoma? discolorations in the perineal area, so assess the perineum very often; pain, pressure on rectum. How will the pain be different than any other pain? Pain meds will NOT control it.so patient will say that the pain meds have not hel ped. What is a priority nursing assessment at this time? Palpate the area, bu t if it is up inside the vagina, palpate with only one gloved finger. What do y ou do if you feel a hematoma? Call the doctor. When? AFTER the assessment. What is REEDA? (look in bookwhole class was answering and I couldnt hear it) What is an approximation? When incision sides are togetherapproximated First 24 hours after vaginal delivery, what are we going to do to help with peri neal pain and swelling? Ice for first 24 hours, then heat, or sitz baths; witch hazel pads or Tucks; sque eze bottle of water to rinse off perineum Whats normal blood loss with a vaginal delivery? 500 ml (? I think I heard) C-Se ction is 1000 mL How will we be culturally sensitive to the patient during their delivery? Talk to patient, ask about values, rituals, special things that may be important to t hem When would we say NO to their request? If want to use fire; a pin on the infant ; Any questions about Formula feeding? Just be sure that they dont add anything to it or try to cut it in half with water to dilute because of financesto make it s tretch. Also, dont microwave to warm because of hot spots; Ready to feed does NO T need to be warmed, but after being opened needs to refrigerate; only fix bottl es for how long? 24 hours!! Dont assume that mothers, no matter their age, know everything about babies. Be sure to teach them all the same at discharge.even if they are educated. Ask, who will be home to help them? And what questions do you have? Dont ask Yes and No questions.it gives no opportunity to elaborate. Bondingwhat will we do to facilitate? Skin to skin for mom and baby. How will w e assess bonding? Is she picking the baby up, attending to its needs? Is someo ne else tending to the baby every time you go in the room? What will you do if

baby is going home today and you have not yet seen the mother hold the baby? Ha nd it to the mama. Assess if she is looking into the babys eyes, bonding with ba by, etc. What if she is not bonding with the baby, and then what will you do? Tell nurse in charge so she can get Social Services involved or else the baby is at risk f or failure to thrive. What kind of things may interrupt bonding? Baby being in NICU; mom in a lot of pain; if baby has an anomaly; Different phases of maternal roles after deliverychart in bookbe sure to look at t hatpage 499 What are the Hunger cues that an infant is hungry? Lip smacking, turn towards b reast when holding, rooting, putting hands in mouth; What about crying? Should mom wait until they cry to feed? NObecause it will be difficult to calm them down to eat at that point. How do you remove baby from breast when finished breastfeeding? Put finger insi de of cheek to break the seal. **Dont get caught up on agonist and antagonist drugsbut know about Stadol and Nuba in. Whats the difference between a spinal and an epidural? The location of the medic ine; with a spinalit is not used for labor and delivery because it is a one-time thing, it cannot be re-dosed; lasts 2-3 hours; good for C-Section, but NOT labor and delivery. It does not last the duration of labor for a vaginal delivery; t his is why we use an epidural-it can be redosed because there is a tube in place to give more meds. I dont know where they get all this spinal-epidural combination stuff; I guess the y could do it but what would be the point? Intrathecal narcotics-what does it mean? If your patient had a spinal and a CSection, they usually give a pain medicine that lasts about 18 hoursthis is what intrathecal means. So for the nurse, this means that you cannot give them any o ther narcotics or pain medicine without checking with the anesthesiologist or OB physician. I have never NOT seen it work. They will be itchy as a side effec t, so can give Benedryl, or may give Nubain, or may give Narcan in the IV fluid. Shaking after deliverypressure and temperature changes in the bodymay also be anes thesia; but it is a NORMAL occurrence. What else is a low blood platelet count related to? The HELLP syndrome. If pla telet count is low, patient cannot have an epidural due to the risk of bleeding at the injection sitethe blood needs to clot so it doesnt mix with spinal fluid or have spinal fluid lead out; This would also cause the classic headache, but we dont see this as often anymore because they use a smaller gauge needle today than they used to. The bigger the hole is the more risk of the spinal fluid to leak out. How do you tell if someone has a spinal headache? If you lay them down the head ache goes away. How do you do a blood patch? Patients own blood is taken out of the antecubital region and reinserted into the injection site. What would the nursing responsi bilities be for this procedure? We might have to draw the blood.