lOMoARcPSD|44532475
Maternal Exam 2
Bonding with Baby:
Face to face & eye contact, positive views of infant, compares infant features to family members,
naming infant, touching, seeking immediate proximity, feeding, changing, responding to cries,
smiling, talks to infant, BREAST feeding
Concerning Behaviors: apathy, disgust when voids, spits up, expression of disappointment,
turning away, no proximity, no talking, rough handling, or ignoring altogether.
Interventions:
skin to skin contact, rooming in, quiet environment, early initiation of BFing, helping as needed,
encourage intervention for readiness cues, infant care teaching to promote maternal confidence
● (When bonding isn’t occurring in the hospital you should call for a social work
consult to follow up after D/C in the home)
Taking in / Dependent Phase: (first 24-48 hrs. 1-3 days) Rely on others for assistance, wants to
relive birth experience, EXCITEMENT.
Taking hold / Independent Phase: (day & lasts 10 days - couple weeks) Seeks acceptance,
takes charge of care for infant, eager to learn & practice,could be w/i first few hours for women
w/o anesthesia
Letting go / Interdependent Phase: Resumes role as an individual, family functions as a unit
Lochia:
Rubra: 1-3 days PP (red)
Serosa: 3-10 days PP (brownish, pink)
Alba: 10-14 days PP (can last 6 weeks) (white, yellowish)
Expected amounts…how much is too much?
● Quantitative blood loss - weighing of pads
o Saturate pad within 15 mins: hemorrhage
o Saturate pad within 1 hr: heavy bleeding
o Weight the pads and quantitative blood loss
▪ Weigh the pad dry and pad wet and subtract them
▪ 1g = 1ml
o Hemorrhage >1,000ml
Describe: Lochia amount is assessed by the quantity of saturation on the perineal pad:
▪ scant: less than 2.5 cm
▪ light: 2.5 – 10cm
▪ moderate: more than 10cm
▪ heavy: one pad saturated within 2hr
Saturating a perineal pad in less than 1 hour is considered an abnormally heavy flow and should
be reported. excessive blood loss: one saturated pad in 15 min or less
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Perineal laceration/Episiotomy Tears: “Post-Partum”
Episiotomy Tear: a surgical incision of the perineum made to prevent tearing of the perineum,
release pressure on the fetal head with birth and possibly shorten the last portion of the second
labor stage
● inspect for hematoma, erythema, edema, intactness, bleeding, drainage
● REEDA Scale (Redness, Edema, Ecchymosis, Discharge, Approximation)
● apply ice or cold pack (indirectly) to perineum first 24 hrs
● heat to perineum + sitz baths AFTER first 24 hrs
● teach perineal exercises
Episiotomy Suture Care: anesthetic cream or spray, hydrocodone or acetaminophen for
discomfort (NO aspirin)
● Sitz bat, peri bottle, durablast spray, high fiber foods, especially fruits, will help
soften stool, lots of fluids, and stool softeners.
● **Teach: NOT to put anything in vagina or rectum until cleared by doctor at 6 week
follow up
Assess Fundal Height in the Postpartum Period:
⇒ one hand at pubic symphysis, one hand above fundus, 1 finger breadth =1 cm
⇒ SHOULD be firm
⇒ Should NOT be boggy = hemorrhage > MASSAGE THE FUNDUS keeping support to the
lower segment of uterus (if not can lead to uterine inversion or hemorrhage)
▪ If the uterus is deviated to the side what to do? -Take the patient to urinate
● Fundus to be after delivery: halfway between umbilicus & symphysis pubis, within 1 hr at
the umbilicus, every 24 hrs goes down 1 cm below umbililcus.
● (1 cm/ 1 finger breadth Q24h)
● Day 1: below umbilicus- 1 cm lower from previous assessment
● Day 2: 2 cm ( another 1 cm lower)
● lower than expected is okay
● HIGHER is BAD (subinvolution r/t flaccidity, full bladder)
Infection Risks Present for the Mom in the POSTPARTUM Period:
● Uterine infection r/t lochia (antibiotics can pass through breast milk causing yeast infection or
cause thrust in baby)
● episiotomy increases risk: leads to peritonitis, septicemia
● Group B strep, staph, E Coli
● Endometritis (c-section, chorioamnionitis)
● Rupture of membranes more than 24 hours before birth
● Refrained placental fragments in uterus
● PP hemorrhage: Pre-existing anemia
● Prolonged & difficult labor, instrumental births (lacerations, tissue trauma)
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● Internal FHM electrode
● Local vaginal infection present at time of birth, Uterus explored after birth
Risk Factors for Postpartum Hemorrhage:
● Uterine atony or history
● Overdistended uterus
● Complications during pregnancy (placenta previa/abruptio)
● Administration of magnesium sulfate during labor
● Inversion of the uterus
● Subinvolution of the uterus
● Hematomas and lacerations
● Retained placental fragments
● Coagulopathies
● Prolonged labor
● Macrosomic baby
Urinary Retention: Epidurals, spinal tap, urinary catheters, vaginal swelling.
Postpartum Preeclampsia:
Symptoms: Increase in HTN severity over first few days, proteinuria, edema, d/t refrained
placental fragment,seizure risk (6-24 h after birth)
Nursing care/Management: Taken for D&C to remove retained placental fragments, bed rest,
quiet atmosphere, frequent vitals, I&O, admin magnesium sulfate, antihypertensives, seizure
precautions.
Meds: GIVE MAG SULFATE!! NO BOLUS.
Risk Factors for Postpartum Depression: S/S
Fatigue, insomnia, forgetfulness, no connection with baby. Tired, helplessness, overwhelming
feeling of sadness.
Occurs: occurs within 6 months of delivery and usually doesn’t resolve without intervention
Interventions:
● Refer the client for a psychological evaluation by the primary care provider, psychologist,
psychiatrist, psychiatric RN, counselor or social worker (particularly one trained in
special needs of women with PPD.
● Reassure the client she’s not alone and that what she’s feeling is real.
● Encourage the client to ask for help with the baby, housework, and meals.
● Teach the client how to maximize sleep.
Downloaded by madiba South Africa stuvia ()
Maternal Exam 2
Bonding with Baby:
Face to face & eye contact, positive views of infant, compares infant features to family members,
naming infant, touching, seeking immediate proximity, feeding, changing, responding to cries,
smiling, talks to infant, BREAST feeding
Concerning Behaviors: apathy, disgust when voids, spits up, expression of disappointment,
turning away, no proximity, no talking, rough handling, or ignoring altogether.
Interventions:
skin to skin contact, rooming in, quiet environment, early initiation of BFing, helping as needed,
encourage intervention for readiness cues, infant care teaching to promote maternal confidence
● (When bonding isn’t occurring in the hospital you should call for a social work
consult to follow up after D/C in the home)
Taking in / Dependent Phase: (first 24-48 hrs. 1-3 days) Rely on others for assistance, wants to
relive birth experience, EXCITEMENT.
Taking hold / Independent Phase: (day & lasts 10 days - couple weeks) Seeks acceptance,
takes charge of care for infant, eager to learn & practice,could be w/i first few hours for women
w/o anesthesia
Letting go / Interdependent Phase: Resumes role as an individual, family functions as a unit
Lochia:
Rubra: 1-3 days PP (red)
Serosa: 3-10 days PP (brownish, pink)
Alba: 10-14 days PP (can last 6 weeks) (white, yellowish)
Expected amounts…how much is too much?
● Quantitative blood loss - weighing of pads
o Saturate pad within 15 mins: hemorrhage
o Saturate pad within 1 hr: heavy bleeding
o Weight the pads and quantitative blood loss
▪ Weigh the pad dry and pad wet and subtract them
▪ 1g = 1ml
o Hemorrhage >1,000ml
Describe: Lochia amount is assessed by the quantity of saturation on the perineal pad:
▪ scant: less than 2.5 cm
▪ light: 2.5 – 10cm
▪ moderate: more than 10cm
▪ heavy: one pad saturated within 2hr
Saturating a perineal pad in less than 1 hour is considered an abnormally heavy flow and should
be reported. excessive blood loss: one saturated pad in 15 min or less
Downloaded by madiba South Africa stuvia ()
, lOMoARcPSD|44532475
Perineal laceration/Episiotomy Tears: “Post-Partum”
Episiotomy Tear: a surgical incision of the perineum made to prevent tearing of the perineum,
release pressure on the fetal head with birth and possibly shorten the last portion of the second
labor stage
● inspect for hematoma, erythema, edema, intactness, bleeding, drainage
● REEDA Scale (Redness, Edema, Ecchymosis, Discharge, Approximation)
● apply ice or cold pack (indirectly) to perineum first 24 hrs
● heat to perineum + sitz baths AFTER first 24 hrs
● teach perineal exercises
Episiotomy Suture Care: anesthetic cream or spray, hydrocodone or acetaminophen for
discomfort (NO aspirin)
● Sitz bat, peri bottle, durablast spray, high fiber foods, especially fruits, will help
soften stool, lots of fluids, and stool softeners.
● **Teach: NOT to put anything in vagina or rectum until cleared by doctor at 6 week
follow up
Assess Fundal Height in the Postpartum Period:
⇒ one hand at pubic symphysis, one hand above fundus, 1 finger breadth =1 cm
⇒ SHOULD be firm
⇒ Should NOT be boggy = hemorrhage > MASSAGE THE FUNDUS keeping support to the
lower segment of uterus (if not can lead to uterine inversion or hemorrhage)
▪ If the uterus is deviated to the side what to do? -Take the patient to urinate
● Fundus to be after delivery: halfway between umbilicus & symphysis pubis, within 1 hr at
the umbilicus, every 24 hrs goes down 1 cm below umbililcus.
● (1 cm/ 1 finger breadth Q24h)
● Day 1: below umbilicus- 1 cm lower from previous assessment
● Day 2: 2 cm ( another 1 cm lower)
● lower than expected is okay
● HIGHER is BAD (subinvolution r/t flaccidity, full bladder)
Infection Risks Present for the Mom in the POSTPARTUM Period:
● Uterine infection r/t lochia (antibiotics can pass through breast milk causing yeast infection or
cause thrust in baby)
● episiotomy increases risk: leads to peritonitis, septicemia
● Group B strep, staph, E Coli
● Endometritis (c-section, chorioamnionitis)
● Rupture of membranes more than 24 hours before birth
● Refrained placental fragments in uterus
● PP hemorrhage: Pre-existing anemia
● Prolonged & difficult labor, instrumental births (lacerations, tissue trauma)
Downloaded by madiba South Africa stuvia ()
, lOMoARcPSD|44532475
● Internal FHM electrode
● Local vaginal infection present at time of birth, Uterus explored after birth
Risk Factors for Postpartum Hemorrhage:
● Uterine atony or history
● Overdistended uterus
● Complications during pregnancy (placenta previa/abruptio)
● Administration of magnesium sulfate during labor
● Inversion of the uterus
● Subinvolution of the uterus
● Hematomas and lacerations
● Retained placental fragments
● Coagulopathies
● Prolonged labor
● Macrosomic baby
Urinary Retention: Epidurals, spinal tap, urinary catheters, vaginal swelling.
Postpartum Preeclampsia:
Symptoms: Increase in HTN severity over first few days, proteinuria, edema, d/t refrained
placental fragment,seizure risk (6-24 h after birth)
Nursing care/Management: Taken for D&C to remove retained placental fragments, bed rest,
quiet atmosphere, frequent vitals, I&O, admin magnesium sulfate, antihypertensives, seizure
precautions.
Meds: GIVE MAG SULFATE!! NO BOLUS.
Risk Factors for Postpartum Depression: S/S
Fatigue, insomnia, forgetfulness, no connection with baby. Tired, helplessness, overwhelming
feeling of sadness.
Occurs: occurs within 6 months of delivery and usually doesn’t resolve without intervention
Interventions:
● Refer the client for a psychological evaluation by the primary care provider, psychologist,
psychiatrist, psychiatric RN, counselor or social worker (particularly one trained in
special needs of women with PPD.
● Reassure the client she’s not alone and that what she’s feeling is real.
● Encourage the client to ask for help with the baby, housework, and meals.
● Teach the client how to maximize sleep.
Downloaded by madiba South Africa stuvia ()
