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53 Cards in this Set
- Front
- Back
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Puerperium |
The period after completion of the third stage of labor until involution of the uterus is complete, usually 6 weeks
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Fourth trimester
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Baby's first three months of life outside the uterus
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Uterine atony
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Relaxation of Uterine Muscle tone following birth (boggy uterus) - number one cause for pph
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Involution
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Rolling or turning inward. The reduction in size of the uterus following child birth. Breast feeding stimulates release of oxytocin and hastens the process.
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Sub involution
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Failure of a part to return to its normal size after functional enlargement, such as failure of the uterus to return to normal size after pregnancy.
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Lochia Rubra
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Dark red discharge remaining after birth. Occurs for the first 2 to 3 days. Contains epithelial cells, erythrocytes, leukocytes, shreds of decidua.
A few small clots no larger than a nickle are normal. Should not contain large plum size clots. |
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Lochia Serosa
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Pinkish colour. Follows from about day 3 until day 10. Composed of serous exudate, shreds of degenerating decidua, erythrocytes, leukocytes, cervical mucus, and microorganisms.
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Lochia Alba
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Creamy or yellowish discharge. Composed primarily of leukocytes, decidual cells, epithelial cells, fat, cervical mucus, cholesterol crystals, and bacteria. Variation of discharge is not uncommon, but should tend towards lighter flow and lighter colour.
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Risk factors for PP Depression
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Prenatal Depression
Childcare stress Life stress Lack of social support Prenatal Anxiety Marital dissatisfaction Premature delivery Multiple gestation Hx of depression Infant temperament Maternity blues Low self esteem Low socioeconomic status Unwanted/Unplanned Pregnancy |
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Role of Nurse in PPD
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Understand risk factors
Recognize symptoms Knowledge of screening methods Treatment options - referrals Realistic Education |
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Depression Assessment
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Sleep Disturbances
Interest decreased in pleasure activities and sex Guilty feelings Energy Decreased Decreased Concentration, appetite, psychomotor function Suicidal Idleations |
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Postpartum Psychosis
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Could hurt self or baby - suicide/homicide
Can occur in first few days after delivery, up to a few weeks after delivery Most serious mood disorder S/Sx: Depression, delusions, hallucinations, fatigue, insomnia, suspicious, to preoccupied with thoughts to provide child care, extreme agitation Should never be left alone with baby Can do involuntary hospitilization for up to 3 days If she does not want to commit herself can call police/mental health Need intense therapy, anti depressant |
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Third Stage of labor
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Delivery of placenta.
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Third Stage of labor - Nursing Assessments
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BP, p, R q5min
Uterine contractions, palpate occasionally until placenta is delivered, fundus maintains tone and contraction patter continues to birth of placenta |
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Third Stage of Labor - Teaching/Management
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Orient to expected assessments and procedures. Answer questions and provide information. Explain comfort measures available.
Straight catch PRN if bladder distended Continues monitoring VS, FHR, and sensation if regional block has been given Position mother to hold newborn, provide encouragement |
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Normal Newborn Evaluation
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Respirations - Rate 30 to 60, irregular, no retractions or grunting
Apical Pulse - 110 bpm to 160, irregular Temperature: 36.5 (97.6) Skin Colour: Pink with blueish extremities Umbilical Cord: Two arteries and one vein\ Gestational Age: Should be 38 to 42 Sole creases: Sole creases that involve the heel |
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Signs of placental seperation
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The uterus rises upwards in the abdomen
As the placenta moves downward, the umbilical cord lengthens A sudden trickle of blood The shape of the uterus changes from a disk to a globe |
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Carboprost Tromethamine (Hemabate)
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Used to reduce blood loss secondary to uterine atony. Stimulates contractions to control postpartum hemorrhaging unresponsive to normal techniques.
Contraindicated in women with active cardiac, pulmonary or renal disease. SE: nausea, diarrhea, fever, chills, flushing. May also cause headache, muscle, join, abdominal, eye pain. Should be given in large muscle, breast feeding withheld for 24 hours |
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Maternal Adaptations following birth
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Blood pressure: returns to prelabor level
Pulse: Slightly lower than in labor Uterine Fundus: In the midline at the umbilicus or 1 to 2 fingerbreadths below the umbilicus Lochia: Red (rubra), small to moderate amount. Doesn't exceed saturation of 1 pad in 1 hour. |
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Immediate Postbirth Danger Signs
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Conditions to be reported to the physician:
Hypotension Tachycardia Uterine atony Excessive Bleeding Hematoma |
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Factors that retard Uterine Involution
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Prolonged labor
Anesthesia Difficult birth Grand multiparity Full bladder Incomplete expulsion of placenta or membranes Infection Overdistentsion of uterus |
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Fundus deviation to the right
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Distended bladder
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Diastasis recti abdominis
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Separation of the abdominal muscle. Increased risk with poor abdominal muscles.
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Pitocin (Oxytocinn)
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Therapeutic: Hormones
Indication: Induction of labor at term, post partum control of bleeding after expulsion of placenta - stimulates uterine smooth muscle, producing uterine contractions w/ vasopressor and antidiuretic effects Contraindicated in: Hypersensitivity, anticipated non vaginal delivery (C - section) AE: coma, seizures, fetal intracranial hemorrhage, fetal asphyxia, hypoxia, maternal increased uterine motility, painful contractions/ Due to Pitocins antidiuretic effect, should assess I &O (hypervolemia/hypertension) Advise patient to expect contractions similar to menstual cramps after administration has started |
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Methergine (methylergonovine)
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Therapeutic: Oxytocic (IM)
Indication:: Prevention and Tx of postpartum hemorrhage, caused by uterine atony or subinvolution AE: Nausea, vomitting, cramps, HYPERTENSION Assessment: Monitor Bp, HR, and uterine response/frequency. Notify hcp if prolonged uterine relaxation or change in bleeding. |
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Prostaglandin E (Cytotec)
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Last resort to stimulate uterine tone
IM straight into uterine muscle AE: Nausea, diarrhea, cramps pph or atony |
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Hemabate F (carboprost tromethamine)
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oxytocic
AE: severe pelvic pain, cramping, severe nausea, vomiting, or diarrhea; or increased blood pressure (severe headache, blurred vision, trouble concentrating, chest pain, numbness, seizure |
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Duramorph
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If present in spinal or epidural respirations are needed every hour for the first 24 hours. Can have respiratory depression and effects peak at 12 to 18 hours.
OD treated with Narcan (noxolone) |
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Most common cause of PPH (postpartum hemorrhage)
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1) Uterine Atony
2) Lacerations or hematoma 3) Retained placenta Vital signs are not a reliable marker, healthy mothers will compensate, watch for heavy lochia (>1 pad/hour) MD should be notified ASAP |
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Important interventions with PPH
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Uterine massage and preventing bladder distension. Firm uterus and express clots.
O2 IV fluid boluses RC Oxytocin IV 2nd line: methergine for bleeding refractory to pitocin 3rd line: hemabate, or prostaglandin F2 |
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What is the second line for PPH, after pitocin?
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methergen for bleeding refractory to pitocin intervention (or prostaglandin E1 or cyotec)
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What is the third line for PPH, after methergen?
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Hemabate or prostaglandin F2
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Magnesium Sulfate
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Indications: Tx of hypertension. Anticonvulsant associated with pre eclampsia or eclampsia.
Contraindicated in: Hypocalcemia AE: Drowsiness, depressed respiratory rate, arrhythmias, bradycardia, hypotension, diarrhea, muscle weakness, flushing, sweating, hypothermia Assessment: monitor BP, resp, and ECG freq. Resp should be >/=16pm. Monitor LOC and reflexes (hold dose if no patellar reflex) Monitor new born for hypotension, hyporeflexia, and respiratory depression |
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Ferrous Sulfate
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Indication: Prevention/Tx of iron deficiency anemia
AE: seizures, hypotension, nausea, constipation, dark stools, diarrhea, epigastric pain, skin staining, anaphylaxis Assessment: bowl function, signs and symptoms of allergic reaction Desired outcome: increase in hemoglobin, improvement in anemia |
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Doscusate sodium (colace)
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Indications: Prevention of constipation in patients who should avoid straining. Usually given BID if 3rd or 4th degree episiotomy. Promotes incorporation of water into stool
Contraindications: hypersensitivity, abdominal pain AE: mild cramps, diarrhea, rashes Administer with a full glass of water. |
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Tucks/Witch hazel
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Witch hazel contains chemicals called tannins. When applied directly to the skin, witch hazel might help reduce swelling, help repair broken skin, and fight bacteria - used in pads to treat hemorrhoids
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Analgesic drugs for breast feeding women
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Acetaminophen, ibuprofen, ketorolac, mirphine
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Antidepressant drugs for breast feeding women
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Setraline, TRICYLIC ANTIDEPRESSANTS
other antidepressants, such as fluoxetine (prozac) may be given with caution |
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Antimicrobial drugs for breast feeding women
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Penicillins, cephalosporins, aminoglycosides, macrolides.
Avoid chloramphenicol and tetracycline |
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Minimizing maternal drug use exposure to neonate via breast feeding
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Dosing immediately after breast feeding (to minimize drug concentrations in milk at the next feeding)
Avoiding drugs that have a long half life Avoiding sustained release formulations Choosing drugs that tend to be excluded from milk Choosing drugs that are least likely to affect the infant Avoiding drugs that are known to be hazardous Using the lower effective dosage for the shortest possible time |
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Naproxen – Aleve
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NSAID
Inhibits prostaglandin synthesis. Prolonged half life. Crosses placenta and enters breast milk in low concentrations. Contraindicated in: Hypersensitivity, lactation, should not be used by nursing mothers A/E: GI disturbances, dizziness, drowsiness, head ache, constipation, hepatitis, GI bleeding, steven johonson syndrome |
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Ibuprofen – Advil, Motrim
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Therapeutic: antipyretics, nonopioid anagesics
Indications: Treatment of mild to moderate pain – inhibits prostaglandin synthesis, does not eneter breast milk in significant amounts Contraindication: Active GI bleeding or ulcer disease, avoid after 30 weeks gestation (may cause premature closure of fetal ductus arteriosus) AE: headache, GI bleeding, hepatitis, constipation, dyspepsia, nausea vomiting, exfoliative dermatitis, steven johnsons syndrome, toxic epidermal necrolysis, anaplylaxis Assessment: Assess pain, look for skin rash |
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Acetaminophen – Tylenol
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Tx of mild pain - analgesia and antipyresis, use only if pregnancy if absolutely needed and cautiously in breast feeding
AE: Hepatotoxcicty Alcohol usage should be assessed before administration |
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Narcan
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Treats refractory nausea and vomiting brought on by duramorph
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Medications for nausea
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Phenergan
Reglan Vistaril Narcan - duramorph Compazine (occasionally) C-section most likely to have nausea |
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Reglan (metoclopramide)
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Therapeutic: antiemetic
Indication: management of gastroesophageal reflux. Tx and prevention of postoperative nausea and vomiting Contraindication: hypersensitivity, possible GI obstruction, hx seizure disorder AE: drowsiness, extrapyramidal reactions, restlessness, neuroleptic malignant syndrome |
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Phenergan (promethazine)
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Therapeutic: antiemetic, antihistamine, sedative, hyponotic (anticholinergic effects)
Indication: treatment and prevention of nausea and vomiting. Adjunct to analgesia. Contraindications: Hypersensitivity, . Safety not established for breast feeding, my cause drowsiness in infant. AE: neuroleptic malignany syndrome, confusion, disorientation, sedation, bradycardia, hypotension, hypertension, tachycardia |
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TOLAC/VBAC
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Trial of labor after C section
Vaginal birth after C section About 66% success rate "once a c-section always a c-section" TOLAC not indicated if we don't know the scar - can use pitocin but not prostaglandin induction agents |
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Pitocin management / complications
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Drug of choice for induction of labor near term. May also be used to cause contraction of the uterus and treat pph (increases uterine tone). Oxytocin is similar in structure to ADH, may promote renal retention of water.
Uterine rupture may occur, especially high risk for trauma in cases of cephalopelvic disproportion, fetal malpresentation, placental abnormalities, umbilical cord prolapse, previous uterine surgery, and fetal distress. Oxytocin is contraindicated in pregnancies with any of these characteristics |
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Cesarean Birth Indications
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Protect health of mother: preexlampsia, co-morbidity, risk uterine rupture, abruptio or previa
Protect health of baby: fetal distress (lates, bradycardia, prolonged develeration, deep variables, sinusoidal), prolapsed cord, malposition, breech, prematurity, large for gestational age (>4400G or 10lb) Failure vaginal delivery: cephalopelvic disproportion, failure to progress, failed operative, shoulder dystocia |
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Cesarean Section Preop Orders / Responsiblities
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NPO after midnight
Consent form EFM/doppler FHR Pre-hydrate LR 500-1000ml Bicitra Clip Prep Assist with positioning RC Dopper FHR after anesthesia - nonstress test Prepare to receive baby 5 - 15 minutes to baby, 30 - 45 min repar, 1 hour recovery |
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Cesarean Section Complications
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Hemorrhage
Infection - would/Pneumonia Injury to other organ Aspiration / Pulmonary Embolus Hypoxia Thrombosis Maternal Death Fetal Death Equivalent of major abdominal surgery |
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Maximum Acetaminophen in 24 hours
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1000mg every 6 hours with a daily maximum of 4000mg
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