Linda and Baby Joey

Linda delivered an 8#5 oz baby boy 2 hours ago. She was just transferred to the postpartum floor with an IV of lactated ringers that will be discontinued when it is finished. Upon assessing her, the postpartum nurse notes that Linda is trickling blood from the vagina and has soaked a pad about 30 to 40 minutes after she changes it. Her VS are: BP 90/68, pulse 102, and RR 28. She appears restless. 1) Name three common sources of PP Hemorrhage: Uterine Atony Lacerations Hematoma Compare and contrast them according to the signs and symptoms, precipitating factors, and treatments. Uterine Atony Boggy uterus shifted to the Right No birth canal injuries that have not been Lacerations Firm uterus Hematoma Firm uterus

Signs and Symptoms

Birth canal injuries that may include cervical tears

No birth canal injuries that have not been sutured

sutured No feelings of pressure

Obvious vaginal bleeding may be dramatic or slight but constant

Usually no complaints of pain VS may indicate shock

No feelings of Feeling of pressure pressure and often complain like they have to have a BM or pelvic heaviness Obvious No obvious vaginal blood loss bleeding with above the a trickle but normal lochia even with a steady trickle the patient can hemorrhage over time Swelling and discoloration of tissue often, but not always visible Usually no Pain out of complaints of proportion to pain normal postpartum VS may VS may indicate indicate shock shock

Precipitating Pitocin Factors induction, large baby, long labor, undelivered placenta, placental fragments, long second stage, full bladder, Treatment Establish cause, but massage is always first step in treatment placenta removal of it or fragments, if bladder, I & 0 cath, if massage doesnt respond Hemabate if not asthmatic,

Traumatic delivery, instrumentati on, pushing prior to completion of dilation,

Trauma, large baby, instramentation , OP presentation, prenatal varicosities, coagulation defects

Locate source of trauma by direct visualization and ligate bleeding vessels

Locate hematoma Surgery may be necessary depending on location

Methergine if not hypertensive

2) What is the normal expected blood loss for a vaginal delivery? Up to 500 ml is normal for a vaginal delivery. Over 1000 is considered a hemorrhage for a c/s. 3) What factors increase the initial blood loss in delivery? Pitocin use in labor, long labors, episiotomies, LGA baby 4) What would you expect her Hgb and Hct to be? Significant changes in Hgb and Hct wont be evident until 4 hours after the hemorrhage. You would expect Hct to drop by 3% points with approx 500ml EBL. Healthy women can usually tolerate HCTs as low as 21% prior to the need for transfusions. 5) Linda is sent home on Iron supplements what discharge teaching is required for patients taking iron supplements? Do not take iron with dairy products, tea, or bran. It is best to try and take them on an empty stomach. Also needs to increase diet with food rich in iron and citrus.

6) On her second day PP, Linda expresses concern that she hasnt had a bowel movement yet? What should you tell Linda? What should she do once she is home?

Normal BM occurs up to 2-3 days PP..increase 3 Fs-Fluids, fruits and fibers. Get up and movelight exercise as ordered. Colace OTC . Call MD as needed for constipation or ABD pain.

Baby Joey has been nursing fairly well. However during the night, Linda calls the night nurse. She is crying and very upset. She tells the nurse that she isnt making enough milk for baby Joey and that she wants to give him some formula. 7) What are some of the implications of Baby Joey being supplemented with formula? May cause nipple confusion, decreased milk supply, decrease incidence in breastfeeding, increased chance of infection 8) How should the nurse respond to the mothers request for formula? Sit with mom and explain supply and demand, importance of colostrum, explain that approx 97% of women that

breast feed can do so without supplementing, have lactation consultant work with mom

9) Linda states that that she really wants to supplement especially since baby Joey has lost weight. What is your response?

Birth weight may drop as much as 5-10% of their BW. Reinforce Linda by explaining ways for her to assess breastfeeding. While you are in with Linda helping her with breast feeding she asks you about the reddened area all over the babys body and also the white spots on Baby Joeys nose?

10) MIlia 11)

What are the white spots on the babys nose?

What is the probable rash on the babys body?

Erythema Toxicum AKA ET rash

12) Linda also is upset because baby Joeys hands and feet are cold to the touch and blue in color? What is this due to? What does Linda need to know about this? This is known as acrocyanosis. By itself, this is a normal variation that results from transient vasomotor instability. It self resolves within 24 hours. If it is present with other signs and symptoms may be more significant and warrants further assessment and notifying the pediatrician.

13) On day 2 Linda is feeling better about breast feeding and states that she thinks the baby is gaining weight. She tells you about the babys intake and output. What is a normal feeding schedule for breast fed babies? What should their output be?

BF Q2-3 hours on demand waking at night for first few weeks. 2-4 wet diapers for first few days once milk is in expect to see a minimum of 4-6 wet diapers. 2-4 bowel movements per day