Infant born to diabetic mothers (IDM) (risks, nursing care)
- Congenital anomalies: cardiac, skeletal, neural tube defects (for infants born to type I DM mothers)
- Causes IUGR, perinatal asphyxia, and SGA neonates due to placental insufficiency in type I DM mothers
- Risk for RDS due to delay in surfactant production
- Risk of hypoglycemia during first few hours due to too much fetal and neonatal insulin
- Neurological damage and seizures and risk for hyperbilirubinemia
- Risk for shoulder dystocia r.t to macrosomia (causes brachial plexus injury)
- Risk for childhood obesity and type 2 diabetes
- Hypocalcemia, hypomagnesemia, low muscle tone, poor feeding abilities
- Nursing care: test glucose on mother 4 times a day, monitor neonate blood glucose (if hypoglycemic, it should be
monitored 30 mins after feeding to evaluate response// 10% dextrose and water IM)
Epidural (risks)
Anesthesia medications:
-epidural is most common form of pain relief. They do NOT provide full sensory and motor block. Monitor UC bc
uterine activity may slow for up to 60 mins. Monitor for tachycardia, dizziness, tinnitus, loss of consciousness
Regional:
-Epidural block: most common is hypotension. N/V/ pruritis, respiratory depression, alterations in FHR,
urinary retention
Postpartum assessment (normal assessment and abnormal assessment findings)
Assessment: BUBBLE: Breasts, Uterus, Bowel and GI Function, Bladder Function, Lochia, Episiotomy
HE- hemorrhoids and emotion
Uterus – begins process of involution, uterus returns to a pre-pregnant size, shape and location and placental site
heals – occurs through UC, atrophy of uterine muscle, decrease in size of cells
-after pains: moderate to severe cramp like pains that are related to uterus working harder to remain contracted or
increase of oxytocin due to infant suckling. Lasts first few days to last 36 hrs. Condition increase with breast feeding
-make pt empty bladder (can cause pain), warm blanket to abdomen, analgesia (ibuprofen), relaxation
-assess uterus q15 mins for 1st hour, q30 mins for 2nd hour, q4 hours for the next 22 hrs and every shift after first 24 hr
- make sure woman voids: over distended bladder can result in uterine displacement and atony
-normal: firm (contracted) vs abnormal: soft (boggy
-boggy uterus: indicates that the uterus is not contracting and places woman at risk for excessive blood loss and
hemorrhage. IMMEDIATE action: massage the fundus (stimulate UC) with palm of your hand in a circular motion
until firm and reevaluate in 30 mins. If uterus does not responds to massage, follow standing order for oxytocin
(promotes UC) and notify MD
- measure distance between fundus and umbilicus: each finger breadth equals 1cm
- a uterus that is SHIFTED to the side may indicate distended bladder -> interferes with UC and increase risk of
uterine atony and hemorrhage
- if uterus is soft, or elevated above the umbilicus, immediate action is to make patient void and reassess
-Expected assessment findings:
- Uterus fundus is palpated midway between umbilicus and symphysis pubis and is firm and midline.
- Within 12 hours after birth, the fundus is at level of umbilicus or 1 cm above umbilicus
- 24 hours after birth of placenta, fundus is 1cm below umbilicus
- Uterus descends 1 cm per day. By day 14, it is not palpable and descended into pelvis
-Endometrium - mucous membrane of uterus, undergoes exfoliation and regeneration after birth
- Lochia: bloody discharge from the uterus that contains sloughed off necrotic tissue
- Metritis: infection of the endometrial tissue
- Assess lochia every time uterus is assessed. Amt of flow is determined by amt of lochia on pad after 1 hr
- Lochia is either scant (<1 inch), light (<4inches), moderate (<6 inches), heavy (saturated within 1 hr)
- Clots are common in lochia but large clot should be weighed and reported to MD. 10g = 10 mL blood loss
, - Excessive bleeding: heavy lochia is a sign of PPH. Assess tone of uterus, if boggy then massage. If displaced
instruct to VOID and reevaluate. If firm change pad and check again in 15min. Continued bleeding with good
fundal tone may indicate presence of genitourinary tract laceration or hematoma of vulva or vagina
- Lochia can increase when getting up in the morning or after sitting for long time.
- Instruct MD IF, sudden increase, bright red bleeding (secondary hemorrhage), foul odor (infection) \
Vagina and Perineum
-Woman may experience mild to severe pain
-Primary complication is infection at the lacerations or episiotomy sites
-Perineum assessed every shift using REEDA (redness, edema, ecchymosis, discharge, approximation of edges of
episiotomy or laceration) – freq assessment can prevent infection, hematoma, excess bleeding
-Expected findings: Mild edema, minor ecchymosis, approximation of the edge of episiotomy or laceration, mild to
moderate pain
- Provide ice to the perineum and use of cold sitz bath for first 24 hrs
- Tell woman to lie on her side (decreases pressure on perineum)
- Instruct to tighten her gluteal muscles as she sits down and relax after she is seated (cushion the perineum and
increases comfort)
- Take warm sitz bath starting 24 hr after delivery BID for 20 mins (promote circulation, healing, comfort)
- Reduce infection: rinse perineum with warm water, change peripad 3-4hrs, wash hands (lochia- medium for
bacteria)
Breasts
-Breast fullness is normal and manifested by swelling of breast tissue
-Primary engorgement: increase in the vascular and lymphatic system of the breasts which precedes the initiation of
milk production, typically occurs 2-3 days after birth
-women may feel breasts become larger, hard, swollen, red, firm, warm and tender and throbbing pain. Subsides
within 24-48 hrs. Women may have elevated temperature. Infant may have difficulty latching on due to engorgement
Treatment for breastfeeding woman: freq feeding to empty breast and prevent milk stasis. Warm compresses
to the breast and breast massage to facilitate flow of milk. Express milk by pump if infant unable to suck.
Ice packs after feedings to reduce inflammation and discomfort. Analgesics for pain and wear supportive
bra
Treatment for NONbreastfeeding woman: wear supportive bra, avoid stimulating the breast, ice packs to
breast, analgesics for pain and subsides within 24 hrs
-Subsequent breast engorgement: for women that breastfeed; relieved by having baby suckle or by expressing milk
For BreastFeeding Women:
-Assess for signs of engorgement: tenderness, firmness, warmth, and enlargement
- Expected findings: First 24 hrs postpartum, breasts are soft and nontender
- On day 2, breasts are slightly firm and non-tender
- On day 3, breasts are firm, tender and warm to touch
-Assess nipples for signs of irritation and nipple tissue breakdown: cracked, blistered or redden areas
-Assess for plugged milk ducts: inadequate emptying of the breast, wearing tight bras or failure to change infant into
different feeding positions. Symptoms: palpation of tender breast BUMPS the size of peas
- Treatment: freq feedings, change feeding position, warm compresses, warm shower before feeding, massaging
breasts before feeding
- Continued milk stasis or unresolved plugged ducts: mastitis and potential breast abcess
- Teaching: apply heat, wear supportive bra, examine nipples for signs of irritation, freq feeding
For Nonbreastfeeding Woman:
-assess for primary engorgement: tenderness, firmness, warmth, enlargement
-milk leakage, breast pain and engorgement may last 1-4 days postdelivery
-Expected findings:
- First 24 hours postpartum, breasts are soft and tender
- Postpartum day 2: breasts are slightly firm and nontender
- Postpartum day 3: breasts are firm and tender
- Congenital anomalies: cardiac, skeletal, neural tube defects (for infants born to type I DM mothers)
- Causes IUGR, perinatal asphyxia, and SGA neonates due to placental insufficiency in type I DM mothers
- Risk for RDS due to delay in surfactant production
- Risk of hypoglycemia during first few hours due to too much fetal and neonatal insulin
- Neurological damage and seizures and risk for hyperbilirubinemia
- Risk for shoulder dystocia r.t to macrosomia (causes brachial plexus injury)
- Risk for childhood obesity and type 2 diabetes
- Hypocalcemia, hypomagnesemia, low muscle tone, poor feeding abilities
- Nursing care: test glucose on mother 4 times a day, monitor neonate blood glucose (if hypoglycemic, it should be
monitored 30 mins after feeding to evaluate response// 10% dextrose and water IM)
Epidural (risks)
Anesthesia medications:
-epidural is most common form of pain relief. They do NOT provide full sensory and motor block. Monitor UC bc
uterine activity may slow for up to 60 mins. Monitor for tachycardia, dizziness, tinnitus, loss of consciousness
Regional:
-Epidural block: most common is hypotension. N/V/ pruritis, respiratory depression, alterations in FHR,
urinary retention
Postpartum assessment (normal assessment and abnormal assessment findings)
Assessment: BUBBLE: Breasts, Uterus, Bowel and GI Function, Bladder Function, Lochia, Episiotomy
HE- hemorrhoids and emotion
Uterus – begins process of involution, uterus returns to a pre-pregnant size, shape and location and placental site
heals – occurs through UC, atrophy of uterine muscle, decrease in size of cells
-after pains: moderate to severe cramp like pains that are related to uterus working harder to remain contracted or
increase of oxytocin due to infant suckling. Lasts first few days to last 36 hrs. Condition increase with breast feeding
-make pt empty bladder (can cause pain), warm blanket to abdomen, analgesia (ibuprofen), relaxation
-assess uterus q15 mins for 1st hour, q30 mins for 2nd hour, q4 hours for the next 22 hrs and every shift after first 24 hr
- make sure woman voids: over distended bladder can result in uterine displacement and atony
-normal: firm (contracted) vs abnormal: soft (boggy
-boggy uterus: indicates that the uterus is not contracting and places woman at risk for excessive blood loss and
hemorrhage. IMMEDIATE action: massage the fundus (stimulate UC) with palm of your hand in a circular motion
until firm and reevaluate in 30 mins. If uterus does not responds to massage, follow standing order for oxytocin
(promotes UC) and notify MD
- measure distance between fundus and umbilicus: each finger breadth equals 1cm
- a uterus that is SHIFTED to the side may indicate distended bladder -> interferes with UC and increase risk of
uterine atony and hemorrhage
- if uterus is soft, or elevated above the umbilicus, immediate action is to make patient void and reassess
-Expected assessment findings:
- Uterus fundus is palpated midway between umbilicus and symphysis pubis and is firm and midline.
- Within 12 hours after birth, the fundus is at level of umbilicus or 1 cm above umbilicus
- 24 hours after birth of placenta, fundus is 1cm below umbilicus
- Uterus descends 1 cm per day. By day 14, it is not palpable and descended into pelvis
-Endometrium - mucous membrane of uterus, undergoes exfoliation and regeneration after birth
- Lochia: bloody discharge from the uterus that contains sloughed off necrotic tissue
- Metritis: infection of the endometrial tissue
- Assess lochia every time uterus is assessed. Amt of flow is determined by amt of lochia on pad after 1 hr
- Lochia is either scant (<1 inch), light (<4inches), moderate (<6 inches), heavy (saturated within 1 hr)
- Clots are common in lochia but large clot should be weighed and reported to MD. 10g = 10 mL blood loss
, - Excessive bleeding: heavy lochia is a sign of PPH. Assess tone of uterus, if boggy then massage. If displaced
instruct to VOID and reevaluate. If firm change pad and check again in 15min. Continued bleeding with good
fundal tone may indicate presence of genitourinary tract laceration or hematoma of vulva or vagina
- Lochia can increase when getting up in the morning or after sitting for long time.
- Instruct MD IF, sudden increase, bright red bleeding (secondary hemorrhage), foul odor (infection) \
Vagina and Perineum
-Woman may experience mild to severe pain
-Primary complication is infection at the lacerations or episiotomy sites
-Perineum assessed every shift using REEDA (redness, edema, ecchymosis, discharge, approximation of edges of
episiotomy or laceration) – freq assessment can prevent infection, hematoma, excess bleeding
-Expected findings: Mild edema, minor ecchymosis, approximation of the edge of episiotomy or laceration, mild to
moderate pain
- Provide ice to the perineum and use of cold sitz bath for first 24 hrs
- Tell woman to lie on her side (decreases pressure on perineum)
- Instruct to tighten her gluteal muscles as she sits down and relax after she is seated (cushion the perineum and
increases comfort)
- Take warm sitz bath starting 24 hr after delivery BID for 20 mins (promote circulation, healing, comfort)
- Reduce infection: rinse perineum with warm water, change peripad 3-4hrs, wash hands (lochia- medium for
bacteria)
Breasts
-Breast fullness is normal and manifested by swelling of breast tissue
-Primary engorgement: increase in the vascular and lymphatic system of the breasts which precedes the initiation of
milk production, typically occurs 2-3 days after birth
-women may feel breasts become larger, hard, swollen, red, firm, warm and tender and throbbing pain. Subsides
within 24-48 hrs. Women may have elevated temperature. Infant may have difficulty latching on due to engorgement
Treatment for breastfeeding woman: freq feeding to empty breast and prevent milk stasis. Warm compresses
to the breast and breast massage to facilitate flow of milk. Express milk by pump if infant unable to suck.
Ice packs after feedings to reduce inflammation and discomfort. Analgesics for pain and wear supportive
bra
Treatment for NONbreastfeeding woman: wear supportive bra, avoid stimulating the breast, ice packs to
breast, analgesics for pain and subsides within 24 hrs
-Subsequent breast engorgement: for women that breastfeed; relieved by having baby suckle or by expressing milk
For BreastFeeding Women:
-Assess for signs of engorgement: tenderness, firmness, warmth, and enlargement
- Expected findings: First 24 hrs postpartum, breasts are soft and nontender
- On day 2, breasts are slightly firm and non-tender
- On day 3, breasts are firm, tender and warm to touch
-Assess nipples for signs of irritation and nipple tissue breakdown: cracked, blistered or redden areas
-Assess for plugged milk ducts: inadequate emptying of the breast, wearing tight bras or failure to change infant into
different feeding positions. Symptoms: palpation of tender breast BUMPS the size of peas
- Treatment: freq feedings, change feeding position, warm compresses, warm shower before feeding, massaging
breasts before feeding
- Continued milk stasis or unresolved plugged ducts: mastitis and potential breast abcess
- Teaching: apply heat, wear supportive bra, examine nipples for signs of irritation, freq feeding
For Nonbreastfeeding Woman:
-assess for primary engorgement: tenderness, firmness, warmth, enlargement
-milk leakage, breast pain and engorgement may last 1-4 days postdelivery
-Expected findings:
- First 24 hours postpartum, breasts are soft and tender
- Postpartum day 2: breasts are slightly firm and nontender
- Postpartum day 3: breasts are firm and tender
