Maternal Newborn ATI Proctored Study Notes

Maternal Newborn ATI Proctored Study Notes Prenatal Lab Tests and Discomforts During Pregnancy IMPORTANT: Rh Factor of mother and baby through indirect Coombs test. If mom is Rh negative and baby is Rh positive, causes mom to build up antibodies that may not affect this pregnancy but WILL attack the next baby’s RBC’s causing them to lyse. If mom is Rh negative and baby Rh positive: Repeat Coombs test at 24-28 weeks. Rhogam will be administered at 28 weeks gestation, which prevents the development of antibodies. Group B Streptococcus: will be checked by taking a vaginal and anal culture around 35-37 weeks gestation. One-hour glucose tolerance test done at 24-28 weeks gestation. No fasting required, if results come back over 140, requires a follow-up 3-hour glucose tolerance test: fasting is required. Maternal serum alpha-fetoprotein: Taken at 15-22 weeks gestation, screens for Down Syndrome of neural tube defects. If LOW: could mean down syndrome. If HIGH: Neural tube defect. Other: CBC, Rubella titer, HIV, Hepatitis B, HPV, STI’s (gonorrhea, chlamydia, syphilis), PPV (check for TB), TORCH infections, and urinalysis Expected Discomforts: - N/V: usually in first trimester. Eat dry toast or crackers in the morning before getting up - Urinary frequency: Empty bladder frequently, use Kegel exercises if stress incontinence’ - UTI’s: Notify if foul smelling or cloudy urine - Heartburn: Advice to eat small, frequent meals, sit up for at least 30 minutes after eating - Fatigue and difficulty breathing: Take frequent rest periods - Constipation: Increase intake of fluid and fiber - Hemorrhoids: Use warm Sitz baths, witch hazel pads - Varicose veins: elevate legs, were compression hose, walk frequently, and avoid standing - Gingivitis, indigestion, and epistaxis (nose bleed): Good oral hygiene, NS spray Nutrition, Weight Gain, and PKU Weight Gain: - Normal weight: total 25-35 pounds. 1st: 2-4lbs. 2nd and 3rd: 1lb per week - Obese: 15-25lbs. - Underweight: 28-40lbs. Calories: No additional calories needed during first trimester. 2nd trimester: extra 340 calories per day 3rd trimester: extra 460 calories per day Breastfeeding: extra 450-500 calories per day Nutrition: FOLIC ACID (IMPORTANT): Prevents neural tube defects. Recommended: 600mcg per day. Increase protein intake, possibly iron supplements (vitamin C increases absorption), calcium 1000mg per day (bone and teeth formation, vitamin D increases absorption). Fluid intake (2-3L per day). Caffeine reduced (200mg per day). NO alcohol. Phenylketonuria (PKU): A genetic disease that causes amino acid Phenylalanine to build up in body which can cause a risk for birth defects in the fetus. IMPORTANT teaching: Adhere to PKU diet 3 months prior to pregnancy and throughout pregnancy. Needs frequent blood Phenylalanine drawn. PKU diet: Very low in protein. Avoid: No meat, fish, poultry, nuts, eggs, or dairy. Ultrasound, BPP, NST, and CST Ultrasound: Noninvasive: Confirm pregnancy, site of implantation, assess baby growth and development and movement. Teaching: Have mom drink a full quart of water prior to procedure to better reflect sound waves. Biophysical Profile: Uses real time ultrasound technology to assess for fetal well-being. Score of 0-10. 8-10 = normal; less than 8 = fetal asphyxia due to insufficient oxygen. FIVE areas: reactive fetal heart rate, fetal breathing movements, gross body movements, fetal tone, and amniotic fluid volume. Non-Stress Test: Non-invasive test that measures fetal HR response to fetal movement. Done in 3rd trimester, acoustic vibration device may help awaken fetus or orange juice. Mom pushes button when she feels movement, provider assesses HR during movement to see if increasing when moving. Preformed when mom reports decreased fetal movement, diabetes, gestational HTN, or post-maturity. Results (IMPORTANT): Reactive: normal finding (HR normal rate, moderate variability, and accelerates at least 2 times in a 20-minute time period). Non-reactive: Abnormal finding, fetal HR does not accelerate sufficiently with fetal movement further assessment is needed Contraction Stress Test: Done after Non-stress test is abnormal or high risk pregnancy. More invasive, help measures fetal HR in response to contractions. Done through nipple stimulation or oxytocin to induce contractions. Results (IMPORTANT): Negative result: Normal finding, no late decelerations with 3 contractions within a 10-minute period. Positive result: Abnormal finding, late decelerations are present for 50% or more of contractions. Can indicate uteroplacental insufficiency. Complications: per-term labor Amniocentesis, CVS, Abortion/Miscarriage, and Ectopic Pregnancy Amniocentesis: Invasive test to test for chromosomal abnormalities and fetal lung maturity. Amniotic fluid is aspirated under ultrasound guidance, performed after 14 weeks gestation. Results: Looking for levels of alpha-fetoprotein, LS ratio (2:1 = fetal lung maturity) Care: Empty bladder prior to procedure, after: administer Rhogam to Rh negative moms, encourage lots of fluid and rest for next 24 hours. Complications: Amniotic fluid emboli, hemorrhaging, infection, leakage of amniotic fluid, pre- mature rupture of membranes, miscarriage. Chorionic Villus Sampling: Portion of placenta is aspirated through a catheter to assess for chromosomal abnormalities. Done between 10-13 weeks gestation. It can be done early! Complications: chorioamnionitis (infection of amniotic fluid and membrane), premature rupture of membranes, miscarriage. Spontaneous abortion: before 20 weeks gestation - Threatened: spotting, no tissue passed, cervix is closed. Fetus can survive this - Inevitable: mild to severe bleeding, no tissue is passed, cervix is dilated and tissue bulging. Abortion will occur. - Incomplete: Severe bleeding, partial fetal tissue past, cervix is dilated - Complete: minimal bleeding, complete fetal tissue passed, cervix is closed Inevitable and incomplete require surgery to clear out contents. DNC procedure, prostaglandins and oxytocin can help remove Ectopic Pregnancy: fertilized ovum is implanted in fallopian tube instead of uterus. Very dangerous for tube rupture and fatal hemorrhaging. S/S (IMPORTANT): Unilateral stabbing pain in LLQ or RLQ, vaginal spotting and bleeding, referred shoulder pain (when ruptured), hemorrhaging (low BP, tachycardia, and pallor) Procedures: Salpingectomy (removal of fallopian tube) or give methotrexate to help dissolve pregnancy and preserve fallopian tube. Trophoblastic Disease, Placenta Previa, and Abruptio Placenta Gestational Trophoblastic Disease: (Molar pregnancy). Abnormal growth of trophoblastic villi in the placenta. Look like grape-like clusters. Prevent embryo from developing and can lead to choriocarcinoma which is a type of cancer. S/S (IMPORTAMT): Dark brown bleeding, N/V. abnormally high hcg levels Diagnose: ultrasound Treatment: evacuation of the mole via cartage or chemo therapy. Placenta Previa: Placenta implants on or near the cervical os vs attaching to fundus at the top. This results in BRIGHT red bleeding during the 3rd trimester. Types: - Complete: covers entirely - Incomplete: covers part of it - Marginal or low-lying: Attaches to lower uterus but does not cover at all S/S: Painless, bright red bleeding in 2nd or 3rd trimester, decreased hematocrit (37-48) and hemoglobin (12-15.5) levels Nursing care (IMPORTANT): Do not perform vaginal examinations or insert anything vaginally, administer IV and blood products as prescribed, educate on bed rest, and if delivery anticipated: give corticosteroids to promote fetal lung growth. Abruptio Placenta: Premature separation of the placenta from the uterus usually in 3rd trimester. High risk form mom and baby morbidity and mortality. Risk factors: HTN, trauma, cocaine use, smoking S/S: intense uterine pain with dark red bleeding, decreased hematocrit (37-48) and hemoglobin (12-15.5) levels, signs of hypovolemic shock (hypotension, tachycardia, pallor), fetal distress Nursing care: Administer IV fluids and blood products, oxygen, corticosteroids. HIV, TORCH, GBS, STIs, Candidiasis HIV: Causes immunodeficiency. Can be transmitted from mom through the placenta or through breastmilk. AVOID: amniocentesis, episiotomy, use of forceps or vacuums, and internal fetal monitors. STANDARD precautions. Nursing Care: Administer antiviral meds to mom throughout the pregnancy and labor. Also administer to infant at delivery and for 6 weeks after birth. Plan for C section if at 38 weeks, if maternal viral load is over 1,000 copies. Give newborn bath immediately after delivery. DO NOT breastfeed baby. TORCH: Most cause flu like symptoms - Toxoplasmosis: undercooked meat or handling cat feces. Educate not to change cat liter - Other: Hepatitis A and B, syphilis, mumps - Rubella: CONTRAINDICATED during pregnancy - Cytomegalovirus: Herpes virus family, droplet transmission - H: Herpes (HSV). Transmission during birth can occur if mom has active lesions Group B Streptococcus Beta-Hemolytic (GBS): Bacterial infection that can result in premature rupture of membranes, preterm labor, can result in chorioamnionitis, UTI’s and sepsis. Will be tested at 35-37 weeks gestation with vaginal and anal swab Nursing Care: Provide antibiotics during intrapartum period if positive screening for GBS or unknown, fever at 100.4 or higher, or rupture of membranes for 18 hours or longer. STI’s: - Chlamydia and gonorrhea: bacterial infections that are often asymptomatic. Can lead to pelvic inflammatory disease, can result in premature rupture of membranes. Treat with antibiotics. In addition, after delivery: all infants are given erythromycin eye ointment within 1-2 hours to help prevent ophthalmia neonatorum (required by law). - Syphilis: Three stages: Primary: you have a chancre, Secondary: skin rash. Third: Internal organ damage. Treated with antibiotics - HPV: Virus that can cause genital warts and cancer. Treated AFTER delivery through creams, laser or other methods - Trichomoniasis: caused by protozoa parasite. S/S: yellow/green malodorous discharge, dysuria, itching. Can lead to pelvic inflammatory disease and infertility., Increase risk for preterm and low birth weight. Treated with antibiotics. Candidiasis: Very common in pregnancy, caused by candida albicans. S/S: thick, white, vaginal discharge, volva erythema, white patches on vaginal wall. Treatment: antifungal meds (fluconazole). Teaching: no tight fitted clothing, wear cotton clothing, no damp clothing, void before and after intercourse, no douching. Incompetent Cervix, Hyperemesis, Anemia, and Diabetes Incompetent Cervix: Premature dilation of cervix which leads to expulsion of fetus. S/S: pelvic pressure, bleeding or pink vaginal discharge, gush of fluids. Procedure to prevent: cervical cerclage. Cervix is sewn close (done 12-14 weeks gestation). Stich is removed around 37 weeks or when spontaneous labor occurs. Teaching: Adhere to activity restriction, bed rest, adequate hydration, and no intercourse. Hyperemesis gravidarum: excess N/V that lasts past 12 weeks of gestation. Possibly related to elevated hcg levels, S/S: N/V, dehydration, electrolyte imbalances, weight loss, ketones in urine, elevate urine specific gravity. Nursing care: monitor I and O’s, weight, and administer IV fluids. Meds: pyridoxine (vitamin B6), antiemetic (metoclopramide [Reglan], or Ondansetron [Zofran]. Refractory: can go on steroids. Iron Deficiency Anemia: caused by inadequate iron stores or insufficient absorption of iron rich foods. S/S: fatigue, pallor, shortness of breath, low hemoglobin (below 11), low hematocrit (below 33), Pica (unusual food cravings Nursing care: encourage increase in iron rich foods (meat, green leafy vegetables, fruit, and beans). Meds: Ferrous sulfate on empty stomach. Vitamin C increase absorption, increase fiber intake because med can cause constipation Gestational Diabetes: Impaired glucose tolerance during pregnancy. Normal 70-110. Risks: Miscarriage, infections, premature rupture of membranes, preterm labor, macrosomia, ketoacidosis, hyperglycemia, hypoglycemia, increased risk of developing diabetes after pregnancy. S/S: Hypoglycemia (headache, weakness, shaky, blurred vision, diaphoresis), hyperglycemia (polyuria, polyphagia, and polydipsia), N/V, fruit breath, GI upset, excess weight gain Diagnose: 1 hr glucose tolerance test (24-28 weeks), if over 140 then 3 hr test (fasting, no caffeine or smoking 12 hours prior to test), glucose measured at 1, 2, and 3 hours after ingestion of 100g of glucose Treatment: Usually insulin, most oral contraindicated. Gestational Hypertension, Preterm Labor, and Premature Rupture of Membranes Gestational HTN: IMPORTANT. Caused by vasospasming that leads to poor tissue perfusion. Can lead to mild then severe preeclampsia, eclampsia then HELP syndrome - Gestational hypertension: BP over 140/90, needs to be taken twice over 4 hours apart, done at 20 weeks gestation. No protein in urine - Mild preeclampsia: elevated BP, proteinuria 1+ or more - Severe preeclampsia: BP over 160/100, more proteinuria 3+ or more. Also, headache, blurred vision, hyperreflexia, peripheral edema, epigastric pain, and elevated creatinine. - Eclampsia: Same as other symptoms but WITH seizures - HELLP Syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets): DANGEROUS. Can lead to anemia, thrombocytopenia, and jaundice. Nursing care: Administer antihypertensive meds (Methyldopa, Nifedipine, Hydralazine, Labetalol), administer anticonvulsants (Magnesium Sulfate: monitor for S/S of Mag. Toxicity: decrease DTR, urine output less than 30ml per hour, resp rate less than 12, decreased LOC, dysrhythmias. Antidote: Calcium gluconate). Education: Bed rest, no foods high in sodium, quiet environment/ Preterm Labor: Uterine contractions with cervical contractions between 20-37 gestation. Risk factors: infection, twins, smoking, substance abuse, diabetes, HTN, placenta previa, PROM. S/S: Vaginal discharge, cervical changes, and uterine contractions. Diagnosis: test vaginal secretions for fetal fibronectin. Medications: Nifedipine (calcium channel blocker) suppress contractions, watch for orthostatic hypotension. Magnesium sulfate to relax smooth muscle in uterus (watch for toxicity), Indomethacin (NSAID) blocks prostaglandin synthesis to suppress labor, Betamethasone (steroid) help promote fetal lung maturity, given 24-48 hours prior to birth. Premature Rupture of Membranes: Prior to true labor. S/S: gush or leaking of clear fluid. Risks: increased risk of infection after rupture (chorioamnionitis), elevated risk if delivery occurs after 24 hrs after rupture. Want it to be within 24 hours. Increased risk for prolapsed umbilical cord. Diagnosis: check for presence of amniotic fluid (positive Nitrzine test), or positive ferning test. Nursing Care: Assess FHR, avoid vaginal exam, test for infection (culture) administer antibiotics, Betamethasone, and prepare for birth. Physiological Changes Before Birth, Stages of Labor Physiological changes: back pain, minimal weight loss, feeling of lightening, contractions, bloody show (brown or bloody mucus discharge), increase energy, GI upset. Rupture: clear, watery fluid discharge. Contractions: - Braxton Hicks: Intermittent, go away if walking, drinks water. No cervical change and fetus is not in pelvis - Labor contractions: Regular (duration and between), will become stronger. Walks, drinks won’t go away. Cervical changes and baby engaged in pelvis. Stages of Labor (IMPORTANT): - 1st Stage: Begins with onset of labor and ends with complete dilation of cervix - 2nd stage: Begins with full dilation and ends with birth of baby - 3rd Stage: Begins with delivery of baby and ends with delivery of placenta - 4th Stage: Begins with delivery of placenta and ends when mom’s vital signs are stabilized. Stage 1 phases: - Phase One: Latent: Cervix dilated 0-3cm, mild to moderate contractions - Phase Two: Active: 4-7cm cervix dilation, moderate to strong contractions - Phase Three: Transition: 8-10cm, strong contractions, feel like they can’t go on at this point. Pressure on pelvis (strong urge to push or have BM) Five P’s in Childbirth 1. Passenger: baby and placenta - Presentation: What part is pointing toward vagina - Lie: Transverse or longitudinal - Attitude: flexed or extended - Position: R or L (back of baby head to mom R or L side), O (occiput-head) S (sacrum-booty) M (mentum-chin) SC (scapula-shoulder), anterior(back of baby head facing towards mom A) posterior (back of head facing mom posterior) or transverse(one side or other). Common: LOA or ROA. Station. Above ischial spine -3, at 0, below +3 2. Passageway: Birth canal 3. Powers: uterine contractions and maternal powers 4. Position: squatting or kneeling 5. Psychological response: Stress can impede labor Pain Management During Labor Nonpharmacological: effleurage (lightly stroke abdomen during contractions), sacral counter pressure (heel of hand to push against sacrum), breathing techniques, imagery, hydrotherapy, music, hot/cold therapy. Pharmacological: - Sedatives: Barbiturates, can lead to neonatal depression so only used in early stage of labor - Opioid analgesic: Meperidine (Demerol). Can lead to sedation, tachycardia, hypotension and Decrease FHR and respiratory depression. Naloxone is antidote. Don’t use until cervix is dilated at least 4cm.Can slow down process - Epidural Blocks: Eliminate sensation from umbilicus to the thigh. Administer when at least 4cm dilated. Key side effect: Maternal hypotension. Also fetal bradycardia is risk factor. - Spinal block: Eliminates sensation from nipples all the way to the feet. Used with C section. Side effect: maternal hypotension, fetal bradycardia, headache if leakage of spinal fluid, and risk for uterine and bladder atony. Nursing care: administer IV fluids to help counter act maternal hypotension (IMPORTANT), position on side to prevent supine hypotension, monitor vital signs continually and FHR patterns continually. Fetal Assessment and Fetal Heart Rate Patterns Leopold Maneuver: Palpate uterus through abdomen to determine fetal lie, fetal attitude, and point of maximum pulse (heartbeat is the loudest) where external detrusor will be placed Normal FHR: 110-160/min, moderate variability, early decelerations NO: late or variable decelerations Accelerations: temporary acceleration in FHR above the baseline, it is reassuring and no intervention is needed. Fetal Bradycardia: FHR below 110 for at least 10 min, can be d/t uteroplacental insufficiency, umbilical cord prolapses, or maternal hypotension, possibly anesthetic medication. Nursing care: Discontinue oxytocin, place mom in side lying position, administer O2 and notify the provider Fetal Tachycardia: FHR over 160 for over 10 min, can be d/t infection, cocaine use, possibly dehydration. Nursing care: administer antipyretics, O2, and possibly IV bolus Early decelerations: slowing of HR during contractions. D/t compression of the baby’s head when contraction is happening. No intervention is needed Late decelerations: slowing of HR after contraction has started and takes a long time to return to baseline. NOT normal. D/t uteroplacental insufficiency. Nursing care: place in side lying position, administer IV fluids, stop oxytocin, and administer o2, palpate uterus for tachysystole, notify provider Variable decelerations: transient variable slowing of the HR. D/t: umbilical cord compression. Nursing Care: place patient in knee/chest position or reposition from side to side, stop oxytocin, and administer O2 Variable Cord Early Head compression Accelerations Okay Late Placental insufficiency Procedures to Assist with Labor and Delivery Internal fetal monitoring: Place an electrode on the fetus’s scalp to closely monitor. Can also use IUPC (Intra-uterine pressure catheter) to monitor strength of contractions (normal 50-80). Over 90: concern. Membranes must be ruptured, dilated at lest 2cm, and presenting part must be descended. Risk: infection of both baby and mom. Only for high risk pregnancy. External cephalic version: Manipulate abdominal wall under ultrasound guidance to help place baby from transverse or breech position to vertex position. Performed after 36 weeks. Increase risk for cord compression and placental abruption (IMPORTANT). Nursing Care: Rh negative mother, be sure she receives Rhogam at 28 weeks gestation. After ECV, patients who are Rh negative require a Kleihauer-Betke test which checks for fetal blood in the maternal circulation, if significant amount is found, then additional Rhogam is given. Also given during procedure, IV fluids, tocolytic meds to help relax the uterus, continually monitor FTR and maternal vital signs. Inducing Labor: - Cervical ripening: Allows for cervical softening, effacement, and dilation. Can be done through balloon catheters, membrane striping, dilators, and chemical agents (Misoprostol). Can be oral or vaginal. - Oxytocin (uterine stimulant, used to increase the strength, the frequency of contractions (monitor contractions and FHR) discontinue IF: contractions more than one minute apart, if contractions last for more than 90 seconds, if contraction intensity is over 90, and if mom’s resting tone is greater than 20. Can administer terbutaline to diminish uterine activity if necessary. - Amniotomy: rupture amniotic membranes using a sharp instrument by the provider to induce labor or in preparation for a amnioinfusion. Risk: cord prolapse (IMPORTANT). Want to make sure presenting part of the fetus is engaged prior to performing amniotomy. Increased risk for infection, delivery should be within 24 hours of procedure - Amnioinfusion: Infusing LR or NS into the amniotic cavity. Done if there is insufficient amniotic fluid in cavity or if cord compression is present. - Vacuum-Assisted Delivery: Applying traction to fetal head with a cup like device. Baby must be in vertex, used if mom is exhausted or having insufficient pushes. Risks: maternal laceration, infant subdural hematoma, or succedaneum - Forceps-Assisted: Used when there is an abnormal fetal position or if there is fetal distress. Risks: maternal lacerations, bladder injury, facial bruising, nerve palsy. Complications During Labor and Delivery: Prolapsed Umbilical Cord: Cord protrudes through cervix before the baby causing cords compression which causes insufficient fetal circulation. Nursing Care: Call for assistance, insert two fingers into the vagina, one finger on each cord and lift the presenting part of the fetus off the cord so the cord is no longer compressed. Then place mom in knee-chest position or Trendelenburg position. Apply warm, saline, moistened gauze over the cord. Meconium stained amniotic fluid: Occurs more when baby is in breach position. Indicates fetal hypoxia if occurs with variable or late decelerations. Nursing Care: Prepare equipment for possible neonatal resuscitation. Dystocia: Difficult or abnormal labor due to uterine abnormalities or small birth canal, or fetal malpresentation. S/S: Insufficient progress in dilation, effacement, and descent. Nursing Care: Encouraging changing position frequently, ambulating, may need to assist with amniotomy, administer Oxytocin. Shoulder dystocia: apply suprapubic pressure to help assist with delivery. Advice to be on hands and knees to assist with changing position of baby. Prepare for forceps assisted or vacuum assisted birth or C section Precipitous labor: Labor lasts less than 3 hours from contractions to when baby is delivered. Risk factors: Hypertonic uterine contractions, oxytocin, and mom who has had previous births. Complications: Mom- lacerations, tissue trauma, uterine rupture, amniotic fluid embolism, or post-partum hemorrhage. Baby – fetal hypoxia due to hypertonic contractions, intercranial hemorrhage due to head trauma. Uterine Rupture: Risk factors: trauma, overdistention of uterus (twins), hyperstimulation of uterus with oxytocin. S/S: severe abdominal pain (feels ripping or tearing), no reassuring FHR patterns, mom is exhibiting signs of hypovolemic shock (tachycardia, hypotension, pallor). Nursing care: Administer IV fluids and blood products, prepare for immediate C section and possible hysterectomy. Amniotic fluid embolism: Infiltration of amniotic fluid into maternal circulation which will travel to and obstruct pulmonary vasculature. Leads to Resp distress and circulatory collapse in mother. S/S: complaining of chest pain, dyspnea, cyanosis, tachycardia, hypotension, or bleeding. Nursing Care: oxygen, IV fluids and blood products and assist in intubation if needed. Postpartum Assessment and Care Fundus: Top of the uterus. After birth should be firm, midline, and at level of umbilicus. At 12 hours will be 1cm above umbilicus, after that it will descend 1-2cm every 24 hours. Day 6 should be halfway between umbilicus and symphysis pubis. By 2 weeks should not be palpable. Nursing Care: assess fundus every 8 hours. Assess height, placement, consistency (should be firm). If displaced laterally: Have patient void. Advice to void every 2-3 hours. Boggy: priority massage fundus in circular motion, give oxytocin to increase contractions and decreases hemorrhaging. Encourage breast feeding which stimulates natural oxytocin and prevent bleeding. Lochia: discharge that occurs after birth. Three stages: 1. Lochia Rubra: Bright red color is expected for 1-3 days after delivery. 2. Lochia Serosa: Pinkish brown color. Lasts 4-10 days after delivery. 3. Lochia Alba: Yellow white color. Lasts 11 days-8 weeks after delivery. Abnormal: Spurting of blood from vagina, saturates pad in under 15 minutes, malodorous indicative of infection, lochia rubra past day three. Check under the patient for pooled lochia. Postpartum care for perineum: Provide stool softeners to avoid straining. Educate on perineum cleaning, after voiding use a squeeze bottle (water and antiseptic solution), wipe front to back, blot dry. Give Ice packs to help with pain and swelling, can use sitz baths twice a day or more, may give pain meds: NSAIDs or opioid analgesics if C section. Topical antiesthetic and witch hazel wipes if she has hemorrhoids. Breasts and Breastfeeding: - Colostrum: Secreted during pregnancy and for 2-3 days after delivery. Rich in protein, antibodies, and fat-soluble vitamins - Milk: Not produced for 3-5 days after delivery. - Teaching: Baby is latched to breast correctly; breastfeeding produces oxytocin which decreases risk for hemorrhaging. Educate on S/S of Mastitis (cracked nipple, flu like symptoms) Post-partum Cardiovascular Changes: Blood loss: vaginal 500ml loss, C section is doubled. After delivery: coagulation factors increased for 2-3 weeks, higher risk for blood clot, elevated WBC count for first week. Steps to prevent DVT: assess legs for signs (unilateral swelling, erythema, and warmth), encourage to ambulate. Post-partum Immune System: Rubella vaccine will be given if titer was less than 8. Advice after vaccine not to get pregnant for one month. Rh negative mothers: administer Rhogam within 72 hours of birth. Hepatitis B vaccine and immune globulin to babies born with infected moms within 12 hours of birth. Others: Varicella and TDaP to patients who don’t have immunity. Maternal Infant Bonding, Paternal and Sibling Adaption Maternal Role Attainment Phases: 1. Dependent/taking in phase: first 24-48 hours after birth, mom relies on others for assistance and eager to share birth experience with others. 2. Dependent/independent/taking hold phase: Around day 2-3 and lasts for several weeks. Mom is focused on learning how to care for baby. 3. Interdependent/letting go phase: mom has developed skills and now can pay attention to her other roles Signs of Impaired bonding: mom ignores baby, disgusted with dirty diapers and spit up, disappointment or apathy in infant, doesn’t talk about infant. Nursing interventions: skin in skin contact, encourage early breastfeeding, educate on hunger cues. Provide support and praise, encourage coloring, diapering, feeding, bathing. Provide community support resources. Paternal Bonding: Signs of good bond: holds, eye contact, verbalizes and recognizes features similar to his own, talking to, singing, reading to infant. Encourage hands on approach. Sibling Adaptation: Can expect regression in toileting and sleeping, if showing aggression or behavior issues can indicate adverse adaptation. Education: sibling being one of first persons to see the baby, provide a gift from the infant to the sibling, preschool: doll to care for. Older: help provide care Postpartum Teaching and Postpartum Complications Teaching: - Breast care: Wash hands prior to breast feeding, wear a supportive bra, drink lots of fluids, and apply breast milk to sore nipples and allow to air dry. Report S/S of Mastitis (crackled, sore nipples, flu like nipples). Engorgement: encourage to empty breasts with each feeding, until softens. Can apply cold compress after eating, and warm compress or warm shower prior to feeding. Fresh and cold cabbage leaves can be applied for engorgement. - Suppression of lactation: Wear supportive bra for first 72 hours and avoid any stimulation (warm water), use mild analgesics, and use cabbage. - Sexual Intercourse: avoid until vaginal discharge has turned white. Episiotomy completely healed. 2-4 weeks. Physical reaction may be diminished for 3 months. Use OTC lubricant for discomfort. Ovulation can occur as early as one month after delivery. Discuss use of contraception Complications: - Increased coagulation factors: high risk for DVT. Prevent: ambulate, avoid immobility, elevate legs, avoid crossing legs, drink fluids, no smoking, wear compression stockings. Nursing care if have: bed rest, elevation above level of heart, never have pillow under knee affected, apply warm, moist compress over area, don’t massage leg, administer analgesics and anticoagulants, implement bleeding precautions - PE: Complication of DVT. S/S: dyspnea, chest pain, tachypnea, hypotension, hypoxia, peripheral edema, bloody sputum. Treatment: Place in semi fowlers, give O2, thrombolytics (ASE), bleeding precautions - Hemorrhaging: Causes: ITP or DIC, uterine atony, precipitous delivery, retained placental parts, lacerations or hematomas, use of Mag. Sulfate, inversion uterus. S/S: Saturates pad in under 15 minutes, blood clots, tachycardia, hypotension, pale, cool skin, constant oozing of blood, H and H decreased. Nursing Care: Uterine atony MASSAGE, administer O2, IV fluid and blood products, elevate legs, administer oxytocin, misoprostol. Postpartum Infections and Mental Health Infections: - Endometritis: RF: C section, retained placental fragments, prolonged rupture of membrane, internal fetal monitoring. S/S: pelvic pain, flu like symptoms, excessive/malodor lochia, increased WBC count. Nursing Care: Collect vaginal and blood cultures, administer antibiotics and analgesics, reinforce good hand hygiene - Mastitis: Infection of breast. RF: Blocked duct, poor breastfeeding technique, bad hand hygiene. S/S: (IMPORTANT) painful reddened area that is hard on one breast, flu like symptoms, WBC elevated. Nursing Care: antibiotics, education: wash hands, frequent breast feed, empty breast with each feeding. Can use pump to help. - UTI: RF: Catherization, frequent vaginal examination, and C section. S/S: urgency, frequency, pain, fever, chills, cloudy, smelly urine. Urinalysis: bacteria, protein, WBC, and RBC. Nursing Care: urine sample, administer antibiotics education: wipe front to back, increase fluid intake, drink cranberry juice Mental Health - Blues: Lasts no more than 10 days after delivery. Symptoms: crying, insomnia, decrease appetite, feeling of let-down. Common, resolves without intervention - Depression: Symptoms: persistent feelings of sadness, intense mood swings, loss of appetite, apathy toward infant, anxiety and panic attacks. Requires intervention. Education: If feelings persist may need intervention. - Psychosis: Within first few weeks. RF: History of bipolar. Symptoms: confusions, delusions, hallucinations, and paranoia. WORRIED: patient and baby at risk for harm. Need immediate help.