Cesarean Birth - NCM 109 PDF

NCM 109 – CARE OF MOTHER, CHILD, AT RISK OR WITH PROBLEMS (ACUTE & CHRONIC) CESAREAN BIRTH COLLADO, DIANA NICOLE D. MR. ALLAN PAULO BLAQUERA, RN ATTENDANCE: SCHEDULE: BUENAVENTURA, NIÑO KAE C. 11/14-15 (STUDY OW...

NCM 109 – CARE OF MOTHER, CHILD, AT RISK OR WITH PROBLEMS (ACUTE & CHRONIC) CESAREAN BIRTH COLLADO, DIANA NICOLE D. MR. ALLAN PAULO BLAQUERA, RN ATTENDANCE: SCHEDULE: BUENAVENTURA, NIÑO KAE C. 11/14-15 (STUDY OWN TOPIC & MAKE OUTLINE) CALATI, KELLY KEITH JANN R. 11/15 (FIRST SGL) CALIGUIRAN, MARIA ERIKA C. 11/15 (FINALIZATION OF HYPOTHESIS) CASTILLO, MICHELLE T. COLLADO, DIANA NICOLE D. 11/16 (PATHOPHYSIOLOGY MAKING) CORTEZ, ELLYZA L. 11/17 (NCP MAKING) DAYAG, CEE JAR MARIE G. 11/18 (FINALIZATION OF PATHOPHYSIOLOGY AND NCP) FABELLAR, AIDON JOSH B. 11/18 (PLENARY FOR SCENARIO 4) GADDAO, CRISTIAN REY I. CESAREAN BIRTH – This procedure is most used often as a prophylactic Size of the fetus. The baby is too large for your measure to alleviate problems of birth such as provider to deliver vaginally. cephalopelvic disproportion, breech or multiple fetus Placenta problems. This includes placenta previa, in births, or failure to progress in labor. which the placenta blocks the cervix. (Premature – surgical delivery of a baby through a cut (incision) made detachment from the fetus is known as abruption.) in the mother's abdomen and uterus Certain conditions in the mother, such as diabetes, – After giving birth via cesarean section there should be a high blood pressure, or HIV infection 3 year gap after the next pregnancy Active herpes sores in the mother’s vagina or cervix Twins or other multiples The incision made in the skin may be: Previous C-section Up-and-down (vertical) – This incision extends from the belly button to the pubic hairline. A. SCHEDULED CESAREAN BIRTH Across from side-to-side (horizontal) – This o Scheduled cesarean births are planned, which means incision extends across the pubic hairline. It's used there is time for thorough preparation for the experience most often, because it heals well and there is less throughout the antepartal period. bleeding. o Women who plan these need to be aware they will need epidural anesthesia, and the risk of injury to them WHY DOES CESAREAN BIRTH DONE? from cesarean birth is higher than that from vaginal Abnormal fetal heart rate birth. o The fetal heart rate during labor is a good sign o Scheduling cesarean births this freely also can result in of how well the fetus is doing. preterm birth with the accompanying threats to the fetus o The normal rate varies between 120 to 160 or newborn beats per minute. o If the fetal heart rate shows there may be a B. EMERGENT CESAREAN BIRTH problem, your provider will take immediate o Emergent cesarean births are done for reasons that action. arise suddenly in labor, such as: o Giving the mother oxygen, increasing fluids, Placenta previa and changing the mother's position. Premature separation of the placenta o If the heart rate doesn’t improve, he or she Fetal distress may do a Cesarean delivery. Failure to progress Abnormal position of the fetus during birth. o With this second type of cesarean birth, preparation o The normal position for the fetus during birth is must be done rapidly. head-down, facing the mother's back. o The woman may not be a prime candidate for Sometimes a fetus is not in the right position. anesthesia and may be psychologically unprepared for This makes delivery more difficult through the the experience. In addition, the woman may have a fluid birth canal. and electrolyte imbalance and be both physically and Problems with labor. Labor that fails to progress or emotionally exhausted from a long labor. doesn't progress the way it should. EFFECTS OF SURGERY ON A WOMAN STRESS RESPONSE INTERFERENCE WITH BODY DEFENSES – Release of epinephrine and norepinephrine from the – The skin serves as the primary line of defense against adrenal medulla bacterial invasion, so when skin is incised for a surgical – Epinephrine increases the heart rate, causes bronchial procedure, this important line of defense is lost. dilatation and elevates the blood glucose level. It also – If the cesarean birth is performed hours after the leads to peripheral vasoconstriction, which forces blood membranes rupture, a woman’s risk for infection will be to the central circulation and increases blood pressure higher than if the membranes were still intact. – In the pregnant woman, such responses may minimize – Many women receive prophylactic antibiotics, such as blood supply to the lower extremities. Pregnant women ampicillin (Omnipen) or a cephalosporin, such as are already prone to thrombophlebitis from stasis of cefazolin (Ancef), to ensure protection against blood flow, so these responses compound or greatly postsurgical endometritis, even if the membranes increase thrombophlebitis risk. remained intact INTERFERENCE WITH CIRCULATORY FUNCTION – The amount of blood lost in a cesarean birth is comparatively high, caused by the fact abdominal and  pelvic vessels are congested with blood waiting to – After a cesarean birth, uterine, bladder, intestinal, and supply the placenta. During a vaginal birth, a woman lower extremity circulatory function must all be carefully loses 300 to 500 ml of blood. This loss increases to 500 assesses. to 1,000 ml with a cesarean birth INTERFERENCE WITH SELF-IMAGE OR SELF-ESTEEM INTERFERENCE WITH BODY ORGAN FUNCTION – Surgery always leaves an incisional scar that is – During cesarean birth the uterus is handled, it may not noticeable to some extent afterward, and its contract well afterward, which can lead to postpartum appearance may cause a woman to feel self-conscious. hemorrhage. For a healthcare provider to reach the Although most women accept cesarean birth well, a uterus, the bladder must be displaced anteriorly. As a woman who was intent on having a vaginal birth may feel a loss of self-esteem and depression if she result of this handling, the bladder may not sense filling believes the procedure marks her as a woman less as well as usual after the procedure capable than others because she was unable to give – During surgery, pressure if also felt by the intestine, so vaginal birth a paralytic ileus or halting of intestinal function with obstruction may occur – Thrombophlebitis from impaired lower extremity blood flow is yet another possibility PREOPERATIVE CARE MEASURES ALTERED GENERAL HEALTH PREOPERATIVE INTERVIEW – Women with secondary illness such as cardiac disease, – An interview with the woman preoperatively to obtain a diabetes mellitus, anemia, kidney, or liver disease is at health history and to make assessment and decisions greater usual surgical risks for safety of the procedure and the use of anesthesia – A general medication history is also important because – Ask about any past surgeries, secondary illnesses, some drugs increase surgical risk by interfering with the allergies to foods or drugs, reactions to anesthesia, effect of an anesthetic or with healing of tissues bleeding problems, or current medications to help establish surgical risks, or any body piercings. DRUGS THAT MAY RESULT IN COMPLICATIONS OF – Include questions to discover the woman’s knowledge CESAREAN BIRTH about: o What the procedure will entail TYPE OF DRUG ACTIONS o Length of hospitalization anticipated o If she’s been told about any postsurgical Antibiotics Specific antibiotics may predispose equipment to be used, such as an indwelling one to renal insufficiency or increase neuromuscular blockage; can lead to catheter or intravenous (IV) fluid line opportunistic infections o Any special precautions that are being planned for her infant such as high-risk nursery care Anticoagulants May cause hemorrhage due to lack of hemostasis during surgery OPERATIVE RISK FOR A WOMAN Anticonvulsants May increase liver action and metabolism of anesthetic agent POOR NUTRITIONAL STATUS Antihypertensives May result in hypotension after – A woman who is obese because of poor nutrition is at anesthesia added risk from surgery, because tissue that contains Corticosteroids May block body’s response to shock an abundance of fatty cells is difficult to suture, thus and so lead to lack of adrenal causing surgical incision to take longer to heal function o A prolonged healing period increases the risk for Insulin May lead to hypoglycemia during infection and rupture of the incision labor or hyperglycemia if a dextrose (dehiscence) solution is administered – A woman with a protein or vitamin deficiency is also at Antianxiety May cause hypotension after risk for poorer healing because protein and vitamins C agents anesthesia and D are necessary for new cell formation at the incision site FLUID AND ELECTROLYTE IMBALANCE o Vitamin K is necessary to ensure blood clotting – A woman who has had a long labor before a cesarean after surgery birth is scheduled may fall into this category because o Iron deficient woman (in particular, women with she may have had little to eat or drink for almost 24 a multiple gestation or women who have not hours. taken supplements) coupled with the blood loss – IV fluid replacement may need to be initiated from surgery, are at high risk for extreme fatigue preoperatively and continued postoperatively to prevent after surgery, which could interfere with parent- a serious fluid or electrolyte imbalance. child bonding FEAR AGE VARIATIONS – Women who are extremely worried about surgery need – Age affects surgical risk because it can cause both a very detailed explanation of the procedure in order to decreased circulatory and renal function reduce their anxiety to a tolerable level. If a woman – Most pregnant women fall within the young adult age seems particularly anxious, inform the team member group, so are excellent candidates for surgery who will administer the anesthesia so that an – A woman older than 40 years falls into a category of antianxiety drug can be administered, if necessary, to slightly higher risk not because of surgery itself but make the experience less frightening for her. because of associated conditions such as gestational diabetes OPERATIVE RISK TO THE NEWBORN – Cesarean birth places a newborn at a greater risk than does a vaginal birth. – When a fetus is pushed through the birth canal, two after birth than those born vaginally. Often pressure on the chest helps rid the newborn’s lungs of referred to as transient tachypnea of the fluid, making it easier for the baby to take a first breath. newborn o More infants born by cesarean birth develop some degree of respiratory difficulty for a day or IMMEDIATE PREOPERATIVE CARE MEASURES PREOPERATIVE DIAGNOSTIC PROCEDURES – Preoperative assessment procedures for a woman who INFORMED CONSENT is to have a cesarean birth include documentation of – Obtaining operative consent is the primary healthcare fetal status and presentation and maturity by ultrasound provider’s responsibility, but being certain, it is obtained assessment. In addition, assessments also include prior to surgery is everyone’s responsibility circulatory and renal function and those for all – Before signing as a witness, be certain that it was presurgery patients, including: informed consent or one in which the risks and benefits o Vital sign determination of the procedure were explained in terms the woman o Urinalysis could easily understand o Complete blood count o Coagulation profile (prothrombin time [PT], OVERALL HYGIENE partial thromboplastin time [PTT]) – On admission, provide a clean hospital gown. If a o Serum electrolyte and pH woman’s hair is long, encourage her to braid it or put it o Blood typing and cross-matching into a ponytail, so it will more easily fit under the surgical cap she will wear; hair contained by a cap is PREOPERATIVE TEACHING less likely to spread microorganisms during surgery. – Preoperative teaching is aimed at acquainting a woman with the cesarean procedure and any special GASTROINTESTINAL TRACT PREPARATION equipment to be used so she is as informed as – A gastric emptying agent, such as metoclopramide possible. (Reglan), to speed stomach emptying or a histamine blocker, such as ranitidine (Zantac), to decrease DEEP BREATHING stomach secretions may be prescribed prior to surgery. – Periodic deep breathing exercises fully aerate the lungs Yet, another possibility is an oral antacid such as citric and help prevent stasis of lung mucus from the acid and sodium citrate (Bicitra), which acts to prolonged time spent in the supine position during neutralize acid stomach secretions. surgery. – These precautions are necessary because the woman o Stasis always has the potential to cause will be lying on her back during the procedure, making infection, preventing this helps prevent lung esophageal reflux and aspiration highly possible. infections such as pneumonia – A typical exercise is to take 5 to 10 deep breaths every BASELINE INTAKE AND OUTPUT DETERMINATIONS hour. The woman simply inhales as deeply as possible, – To reduce bladder size and keep the bladder away from holds her breath for a second or two, and then exhales the surgical field, an indwelling urinary catheter may be as deeply as possible. prescribed before transport for surgery or after arrival in – Be certain she both inhales and exhales fully. the surgical suite. Otherwise, she might experience light-headedness from hyperventilation. HYDRATION – Most women have an IV fluid line begun before surgery INCENTIVE SPIROMETRY with a fluid such as lactated Ringer’s solution. Doing so – Incentive Spirometer helps to ensure a woman will be fully hydrated and will o Used to three to four times a day postoperatively not experience hypotension from epidural anesthesia to encourage deep breathing administration, temporary use of a supine position, or o Cause a small ping-pong-like-ball to rise in a blood loss at birth. narrow tube or cause lights to flash, are both easy and fun to operate and give a woman a PREOPERATIVE MEDICATION sense of reward for her effort – A minimum of preoperative medication is used with a o Most models are triggered by inhalation, not woman having a cesarean birth to prevent exhalation compromising the fetal blood supply and to ensure that o A gauge can be set to monitor levels and tabs to the newborn is wide awake at birth and can initiate set goals respirations spontaneously. TURNING PATIENT CHART AND PRESURGERY CHECKLIST – Be certain women understand that turning – Documentation of nursing care up until the time a postoperatively is important to prevent both respiratory woman leaves the nursing care unit or labor room must and circulatory stasis. be completed before a woman leaves for the surgical suite. AMBULATION – The most effective way to stimulate lower extremity TRANSPORT TO SURGERY circulation after a cesarean birth is by early ambulation – A woman may be transferred to surgery in her bed, or – Ambulation is extremely important after cesarean birth she may be helped to move to a stretcher. because the edema from the low pelvic surgery – Urge her to lie on her left side during transport to compresses circulation to the lower extremities, thus prevent supine hypotension syndrome. increasing the risk for lower extremity circulatory stasis – Ensure additional safety by raising the side rails. Cover – Some women may be prescribed sequential her with a blanket or sheet to avoid her feeling chilled. compression devices (SCDs) or antiembolic stockings – Check that her identification is secure before she (thromboembolic devices [TEDs]) to support and leaves the patient unit. Make certain, even though steps encourage venous return in addition to ambulation are being completed rapidly, that her chart or electronic  record remains secure and will be available to OR ROLE OF THE SUPPORT PERSON personnel. – Helping family members realize cesarean birth is little different from vaginal birth not only allows them to stay with a woman during the procedure but also helps them progress to bonding with the infant and incorporating the new member into their family more easily. NURSING CARE FOR A WOMAN HAVING AN EMERGENT CESAREN BIRTH – Many women who will have a cesarean birth have no tract, adding bladder catheterization, and establishing warning during pregnancy that a cesarean birth will be an IV line. necessary. Suddenly, during labor, they develop a – Because, ideally, a cesarean birth should be completed complication such as prolapsed cord or fetal distress, within 30 minutes from the time the procedure was and surgery becomes necessary. documented to be necessary, teaching about – An immediate preparation, therefore, involves gaining postoperative measures needs to be delayed until after an informed consent, application of SCDs or elastic surgery stockings (if appropriate), preparing the gastrointestinal INTRAOPERATIVE CARE MEASURES ADMINISTRATION OF ANESTHESIA CLASSIC CESAREAN INCISION – During transport and while in surgery, encourage the – The incision is made vertically through both the woman to remain on her side, or place a pillow under abdominal skin and the uterus. It is made high on the her right hip to keep her body slightly tilted to the side, uterus, so that it avoids cutting a possible placenta to prevent supine hypotension syndrome. previa. – If a spinal anesthetic (which may be used in an – Disadvantage: it leaves a wide skin scar and also runs emergency) is to be administered, the anesthesiologist through the active contractile portion of the uterus usually will do this with the woman sitting up. The anesthesiologist may then ask you to help the woman LOW SEGMENT INCISION (LOW TRANSVERSE curve her back to separate the vertebrae and facilitate UTERINE INCISION & PFANNENSTIEL SKIN INCISION) entry of the spinal needle. – One made horizontally across the abdomen just over – Epidural anesthesia is usually administered with the the symphysis pubis and also horizontally across the woman lying on her side. uterus just over the cervix o Duramorph is a form of morphine commonly – Most common type of cesarean incision used today used in addition to a local anesthesia in – Also referred to as a Misgav-Ladach or a “bikini” epidurals. Its effect lasts up to 24 hours, but incision because even a low-cut bathing suit will cover because it can cause late occurring respiratory the scar depression, respirations should be assessed – This incision in through the nonactive portion of the every 2 hours postsurgery uterus (the part that contracts minimally with labor) it is less likely to rupture in subsequent labors, making it SKIN PREPARATION possible for a woman to have a vaginal birth after – Reducing the number of bacteria on the skin before cesarean (VBAC) surgery automatically reduces the possibility of bacteria – The low segment incision is preferred because it: entering the incision at the time of surgery. Shaving o Results in less blood loss away abdominal hair, if indicated, and washing the skin o Is easier to suture area over the incision site with soap and water o Decrease postpartal uterine infections accomplishes this. o Is less likely to cause postpartum gastrointestinal complications SURGICAL INCISION – DISADVANTAGE: it takes longer to perform, possibly – Positioned with a towel under her right hip to move making it impractical for an emergent cesarean birth abdominal contents away from the surgical field and to life her uterus off the vena cava. BIRTH OF THE INFANT – Once the surgical incision is complete, the uterus is TYPE OF CESAREAN INCISION then cut and the child’s head is born manually – The mouth and nose of the baby may be suctioned by a bulb syringe, before the remainder of the child is born – Oxytocin (Pitocin) is administered via IV by the anesthesiologist as the child or placenta is delivered to increase uterine contractions and reduce blood loss INTRODUCTION OF THE NEWBORN – Women are able to breastfeed after cesarean births the same as after vaginal births. However, initial breastfeeding may be delayed until the woman has been moved to a recovery room along with her infant because breastfeeding is difficult to do while still in the operating room due to position and monitors or IVs attached to the mother. – Women are able to breastfeed after cesarean births the same as after vaginal births. However, initial  breastfeeding may be delayed until the woman has operating room due to position and monitors or IVs been moved to a recovery room along with her infant attached to the mother. because breastfeeding is difficult to do while still in the POSTPARTAL CARE MEASURES – Women who have a cesarean birth develop an additional care concern in the immediate postpartal period because they are not only postpartal patients but postsurgical ones. In addition to afterpains from their contracting uterus, they have postsurgical incision pain. A goal of nursing care should be to help women bond successfully with their new infant. MEASURES TO REGAIN ENERGY AFTER A CESAREAN BIRTH Drink adequate fluid daily (at least six glasses). This helps prevent a urinary tract infection and also helps supply all the cells in your body with adequate fluid Rest twice a day for at least one-half hour each time. This helps you get adequate sleep in your baby wakes you at night Do not hesitate to accept help from family and friends for tasks such as house cleaning or grocery shopping Limit the number of stairs you climb daily to one flight once a day. Also limit the amount of weight you lift to the weight of your new baby Do not attempt to be a social hostess as well as a new mom. Put your energy toward relaxing and enjoying your new baby. DISCHARGE PLANNING Be certain to discuss home care arrangements, emphasizing the need for adequate help with her newborn and other responsibilities at home Be sure a woman is aware of any restrictions on exercise or activity she needs to follow o Common restrictions are not to lift any object heavier than 10 lb or walk upstairs more than once a day for the first 2 weeks) Teach the client how to recognize signs of possible complications directly related to the surgery that should be reported to her primary care provider, including: o Redness or drainage at the incision line o Lochia heavier than a normal menstrual period o Abdominal pain (other than suture line or afterpain discomfort) o Temperature greater than 38ºC (100.4ºF) A woman can plan on resuming coitus as soon as the act is comfortable for her o Cesarean birth does not interfere with future fertility, so be sure she has contraceptive information Ensure the patient has an appointment for a return visit with her healthcare provider for both herself (usually in 2 to 4 weeks) and her newborn (usually 1 to 2 days)  NCM 109 – CARE OF MOTHER, CHILD, AT RISK OR WITH PROBLEMS (ACUTE & CHRONIC) POSTPARTUM HEMORRHAGE COLLADO, DIANA NICOLE D. MR. ALLAN PAULO BLAQUERA, RN HEMORRHAGE A. UTERINE ATONY – One of the primary causes of maternal mortality – Relaxation of the uterus associated with childbearing – The most frequent cause of postpartum hemorrhage – It is a major threat during pregnancy, throughout labor, and continuing into the postpartum period. CONDITIONS THAT INCREASE A WOMAN’S RISK FOR A – It is defined as blood loss of 500 ml or more following a POSTPARTAL HEMORRHAGE vaginal birth – With a cesarean birth, hemorrhage is present when Multiple gestations there is a 1000 ml blood loss or a 10% decrease in the Conditions that Polyhydramnios (excessive hematocrit level distend the uterus amount of amniotic fluid) – Hemorrhage may occur either: beyond average A large baby (>9 lb) o Early – within the first 24 hours following birth capacity The presence of uterine myomas o Late – from 24 hours to 6 weeks after birth (fibroid tumors) The greatest danger is in the first 24 hours because of Conditions that could the grossly denuded and unprotected uterine area left An operative birth have caused cervical after detachment of the placenta or uterine lacerations A rapid birth FOUR MAIN REASONS FOR POSTPARTUM Placenta previa HEMORRHAGE Conditions with varied Placenta accrete A. Uterine atony placental site of Premature separation of the B. Trauma (lacerations, hematomas, uterine inversion, or attachment placenta uterine rupture) Retained placental fragments C. Retained placental fragments Deep anesthesia or analgesia D. Development of disseminated intravascular coagulation Labor initiated or assisted with an (DIC) oxytocin agent High parity or maternal age over These are generally referred to as the four T’s of 35 years of age postpartum hemorrhage: tone, trauma, tissue, and Previous uterine surgery thrombin – a common mnemonic for the etiology of Conditions that leave Prolonged and difficult labor hemorrhage experienced in the puerperium the uterus unable to Chorioamnionitis or contract readily endometriosis Secondary maternal illness such as anemia Prior history of postpartum hemorrhage Prolonged used of magnesium sulfate or other tocolytic therapy Conditions that lead Fetal death to inadequate blood Disseminated intravascular coagulation coagulation (DIC) THERAPEUTIC MANAGEMENT 1. FUNDAL MASSAGE First step in controlling hemorrhage is to attempt fundal massage to encourage contraction o This procedure is usually effective in causing contraction and after a few seconds, the uterus assumes its healthy, grapefruit-like feel With uterine atony, even if the uterus responds well to massage, the problem may not be completely resolved because, as soon as you remove your hand from the fundus, the uterus may relax and the lethal seepage will begin again. o To prevent this, remain with a woman after massaging her fundus and assess to be certain her uterus is not relaxing again. o Continue to assess carefully for the next 4 hours. Oxytocin’s action on the uterus is immediate. It has a short duration (1 hour) so symptoms of uterine atony can recur quickly if it is administered only as a single dose If oxytocin is not effective at maintaining tone, carboprost thromethamine and methylergonovine maleate can be given  Carboprost tromethamine (Hemabate) a 4. HYSTERECTOMY OR SUTURING prostaglandin F2a derivative, or With extreme bleeding, embolization of pelvic and – May be repeated every 15 to 90 minutes up to 8 uterine vessels by angiographic techniques may be doses; necessary methylergonovine maleate (Methergine) an ergot As a last resort, ligation of the uterine arteries or a compound, both given IM, are second possibilities hysterectomy (removal of the uterus) may be – May be repeated every 2 to 4 hour up to 5 doses necessary Misoprostol (Cytotec) a prostaglandin E1 analogue, may also be administered rectally to decrease B. LACERATIONS postpartum hemorrhage – Small lacerations of tears of the birth canal are common – A second dose of misoprostol should not be and may be considered a normal consequence of administered unless a minimum of 2 hours has childbearing elapsed. – Large lacerations can be sources of infections or hemorrhage. They occur most often: ® Side effects of prostaglandins: diarrhea and nausea o With difficult or precipitate births ® Be aware that all of these medications can increase o In primigravidas blood pressure and so must be used cautiously in o With the birth of a large infant (>9 lb) women with hypertension o With the use of a lithotomy position and ® Assess blood pressure prior to administration and about instruments (e.g., forceps, vacuum extraction) 15 minutes afterward to detect this potentially – Lacerations may occur in the cervix, vagina, or the dangerous side effect perineum. o After birth, anytime a uterus feels firm but ADDITIONAL MEASURES THAT CAN BE HELPFUL TO bleeding persists, suspect a laceration at one of COMBAT UTERINE ATONY INCLUDE: these three sites is causing the bleeding Elevate the woman’s lower extremities to improve circulation to essential organs. CERVICAL LACERATIONS Offer a bedpan or assist the woman to the bathroom at – Lacerations of the cervix are usually found on the sides least every 4 hours to be of the cervix, near the branches of the uterine artery. certain her bladder is emptying because a full bladder – If the artery is torn, the blood loss may be so great that predisposes a woman to uterine atony. To reduce the blood gushes from the vaginal opening. possibility of bladder pressure, insertion of a urinary o Because this is arterial bleeding, it is a brighter catheter may be prescribed. red than the venous blood lost with uterine atony Administer oxygen by face mask at a rate of about 10 to o Fortunately, this bleeding ordinarily occurs 12 L/min if the woman is experiencing respiratory immediately after detachment of the placenta, distress from decreasing blood volume. Position her when the primary care provider is still in supine (flat) to allow adequate blood flow to her brain attendance and kidneys. Obtain vital signs frequently and assess them for trends THERAPEUTIC MANAGEMENT such as a continually decreasing blood pressure with a The repair of a cervical laceration usually requires continuously rising pulse rate. sutures and can be difficult because if the bleeding is intense, this obstructs visualization of the area. 2. BIMANUAL COMPRESSION Try to maintain an air of calm and if possible stand If fundal massage and administration of uterotonics beside the woman at the head of the table. (drugs to contract the uterus) are not effective at If the cervical laceration appears to be extensive or stopping uterine bleeding, a sonogram may be done to difficult to repair, it may be necessary for the woman to detect possible retained placental fragments be given a regional anesthetic to relax the uterine Bimanual compression is a procedure where the muscle and to prevent pain. primary care provider inserts one hand into a woman’s vagina while pushing against the fundus through the VAGINAL LACERATIONS abdominal wall with the other hand – They are easier to locate and assess than cervical lacerations because they are so much easier to view 3. BLOOD REPLACEMENT – Vaginal tissue is friable, making vaginal lacerations Blood transfusion to replace blood loss with postpartal difficult to suture hemorrhage is often necessary Iron therapy may be prescribed to ensure good THERAPEUTIC MANAGEMENT hemoglobin formation A balloon tapenade similar to the type used with a Extensive blood loss is one of the precursors of uterine hemorrhage may be effective if suturing does postpartal infection because of the general debilitation not achieve hemostasis that results An indwelling urinary catheter (Foley catheter) may be placed following the repair because the packing causes NURSING INTERVENTIONS: such pressure on the urethra that it can interfere with Observe any woman who has experienced more voiding. than a normal loos of blood for changes such as scant or odorous lochia discharge. PERINEAL LACERATIONS Monitor her temperature closely in the postpartal – Lacerations of the perineum are more apt to occur period to detect the earliest signs of developing when a woman is placed in a lithotomy position for birth infection rather than a supine position Make certain the woman knows how to assess for o A lithotomy position increases tension on the normal lochia and temperature once she is perineum discharged – Perineal lacerations are sutured and treated the same THERAPEUTIC MANAGEMENT as an episiotomy repair Removal of the retained placental fragment is – Perineal lacerations are classified by four categories, necessary to stop the bleeding and can usually be depending on the extent and depth of the tissue accomplished by a dilatation and curettage (D&C). involved. If it cannot be removed, methotrexate may be prescribed to destroy the retained fragment. CLASSIFICIATION OF PERINEAL LACERATIONS Be certain women know to continue to observe the color of lochia and to report any tendency for the Classification Description of Involvement discharge to change from lochia serosa or alba back to First degree Vaginal mucous membrane and skin rubra. of the perineum to the fourchette Second degree Vagina, perineal skin, fascia, levator D. UTERINE INVERSION ani muscle, and perineal body – Uterine inversion is a prolapse of the fundus of the Third degree Entire perineum, extending to reach uterus through the cervix so that the uterus turns inside the external sphincter of the rectum out. This usually occurs immediately after birth. Fourth degree Entire perineum, rectal sphincter, and some of the mucous membrane E. DISSEMINATED INTRAVASCULAR COAGULATION of the rectum – DIC is a deficiency in clotting ability caused by vascular injury. It may occur in any woman in the postpartal THERAPEUTIC MANAGEMENT period, but it is usually associated with premature Make certain the degree of the laceration is separation of the placenta, a missed early miscarriage, documented because women with fourth-degree or fetal death in utero. lacerations need extra precautions to avoid having sutures loosened or infected F. SUBINOVULATION A diet high in fluid and a stool softener may be – It is the incomplete return of the uterus to its prescribed for the first week after birth to prevent prepregnant size and shape. With subinvolution, at a 4- constipation and hard stools, which can break the or 6-week postpartal visit, the uterus is still enlarged new sutures. and soft. Any woman who has a third- or fourth-degree laceration – Lochia discharge usually is still present. should not have an enema or a rectal suppository – Subinvolution may result from a small retained prescribed or have her temperature taken rectally placental fragment, a mild endometritis (infection of the because the hard tips of equipment could open sutures endometrium), or an accompanying problem such as near to or including those of the rectal sphincter. uterine myoma that is interfering with complete contraction. C. RETAINED PLACENTAL FRAGMENTS – A placenta does not detach in its entirety; fragments of THERAPEUTIC MANAGEMENT it separate and are left still attached to the uterus Oral administration of methylergonovine, 0.2 mg four o Because the portion retained keeps the uterus times daily, is the usual prescription to improve uterine from contracting fully, uterine bleeding occurs. tone and complete involution. § Although this is most likely to happen If the uterus feels tender to palpation, suggesting with a succenturiate placenta – a endometritis is present, an oral antibiotic also will be placenta with an accessory lobe prescribed. – Placenta accrete (a placenta that fuses with the A chronic loss of blood from subinvolution will result in myometrium because of an abnormal decidua basalis anemia and a lack of energy, conditions that possibly later – may also be retained. could interfere with infant bonding or lead to infection. o This is associated with previous cesarean birth and in vitro fertilization G. PERINEAL HEMATOMAS o It can be identified by an ultrasound exam during – is a collection of blood in the subcutaneous layer of pregnancy tissue of the perineum. – Removing such a deeply embedded placenta can lead – The overlying skin, as a rule, is intact with no noticeable to severe postpartal hemorrhage trauma. – To identify complication of a retained placenta, every – Blood accumulates underneath, however, from injury to placenta should be inspected carefully after birth to be blood vessels in the perineum during birth. certain it is complete. – Hematomas are most likely to occur after rapid, – Retained placental fragments may also be detected by spontaneous births and in women who have perineal ultrasound. varicosities. – A blood serum sample that contains human chorionic – They may occur at the site of an episiotomy or gonadotropin (hCG) hormone also reveals that part of a laceration repair if a vein was punctured during placenta is still present. suturing. – Although these can cause a woman acute discomfort ASSESSMENT and concern, they usually represent only minor If an undetected retained fragment is large, bleeding bleeding. will be apparent in the immediate postpartal period because the uterus cannot contract with the fragment in ASSESSMENT place. If a woman reports severe pain in the perineal area or a If the fragment is small, bleeding may not be detected feeling of pressure between her legs, inspect the until postpartum day 6 to 10, when the woman notices perineal area to see if a hematoma could be causing an abrupt discharge and a large amount of vaginal this. bleeding. On examination, usually the uterus is found to not be fully contracted.  o If present: § area of purplish discoloration with obvious swelling (2 cm or as large as 8 cm in diameter) § It palpates as a firm globe and feels tender THERAPEUTIC MANAGEMENT Report the presence of a hematoma, its estimated size, and the degree of the woman’s discomfort to her primary care provider. Administer a mild analgesic as prescribed for pain relief. Applying an ice pack (covered with a towel to prevent thermal injury to the skin) may prevent further bleeding. Be certain the woman has clear instructions before discharge regarding necessary suture line care she will need to do at home, such as keeping it clean and dry and perhaps using a sitz bath once or twice a day.  NCM 109 – CARE OF MOTHER, CHILD, AT RISK OR WITH PROBLEMS (ACUTE & CHRONIC) HYPOVOLEMIC SHOCK CALIGUIRAN, MARIA ERIKA C. MR. ALLAN PAULO BLAQUERA, RN HYPOVOLEMIC SHOCK LUNGS – Is an emergency condition in which severe blood and Tachypnoea due to central nervous system fluids loss make the heart unable to pump enough chemoreceptor stimulation by a decreased pH and blood to the body due to decrease preload. hypoxia. – It leads to multiple organs failure. BRAIN Symptoms are duo to cerebral hypoperfusion and PROCESS OF SHOCK BECAUSE OF BLOOD LOSS acidosis. Shock Shock class Shock Shock class – The uterus is a class I II class III IV nonessential None or Restlessness Anxiety Confusion body organ, orthostatic Anxiety Confusion Drowsiness danger to the dizziness agitation And coma fetal blood supply occurs ASSESSING A PREGNANT WOMAN WITH when a HYPOVOLEMIC SHOCK woman’s body begins to decrease blood flow to peripheral organs (although the increased blood volume of pregnancy allows more than normal blood loss before hypovolemic shock processes begin). – Because “normal” blood pressure varies from woman to woman, it is important to know the baseline blood pressure for a pregnant woman when evaluating for hypovolemic shock. EFFECT OF HYPOVOLEMIC SHOCK KIDNEYS The urine output will decrease do to renal hypoperfusion HEART Cardiovascular signs are duo to adrenergic response to blood loss. SIGNS AND SYMPTOMS Shock Shock class II Shock Shock class class I class III IV Assessment Significance NONE Tachycardia Tachycardia Tachycardia, Increased pulse Heart attempts to circulate decreased due to very weak rate blood volume. catecholamine pulse Decreased blood Less peripheral resistance is present release pressure because of decreased blood volume. Weak pulse or Hypotension Capillary refill Increased Respiratory system attempts to absent pulses is respiratory rate increase gas exchange to better (they are more undetectable. oxygenate decreased red blood cell significant than volume. weak pulses). Cold, clammy Vasoconstriction occurs to maintain Skin, pale, The skin is pale skin blood volume in central body core. moist, and and moist. Decreased urine Inadequate blood is entering kidneys cool. output because of decreased blood volume Blood pressure Dizziness or Inadequate blood is reaching very low or decreased level cerebrum because of decreased undetectable of consciousness blood volume. Decreased Decreased blood is returning to heart central venous because of reduced blood volume. pressure  OTHER INFORMATION EMERGENCY INTERVENTIONS FOR BLEEDING IN Measured blood loss up to 1000 ml is well tolerated by PREGNANCY healthy pregnant women. This is partly due to physiological increases in plasma volume and red cell INTERVENTION RATIONALE mass during pregnancy. Alert healthcare team of Provides maximum Hypovolemic shock is a major cause of maternal emergency situation coordination of care mortality. Place woman flat in bed on Maintains optimal placenta Management requires teamwork, co-ordination, speed, her side function and adequate facilities to be lifesaving. Begin intravenous fluid Replaces intravascular fluid o The first priority is rapid fluid replacement. such as Ringer’s lactate volume; intravenous line is Evidence from randomized trials has established with a 16- or 18- gauge established if blood that crystalloids are the fluids of choice over Angiocath replacement will be needed colloids and particularly albumen, which was Administer oxygen as Provides adequate fetal associated with increased mortality. necessary at 6-10 L/min by oxygenation despite Rapid access to blood or blood products for transfusion face mask lowered maternal circulating is necessary, as well as laboratory back-up. Further blood volume management includes accurate assessment of the site Monitor urine contractions Assesses whether labor is of bleeding; control of the bleeding; diagnosis and and fetal heart rate by present and fetal status; management of the underlying condition; supportive external monitor external system avoids therapy; and monitoring of the clinical, hematological, cervical trauma and biochemical response to treatment. Omit vaginal examination Prevents tearing of placenta Maternal shock is the result of an inadequate supply of if placenta previa is cause oxygenated blood to tissues; it can be the result of a of bleeding number of different medical conditions. During Withhold oral fluid Anticipates need for pregnancy and delivery, maternal shock often is caused emergency surgery by hemorrhaging or septic infection. Order type and cross- Allows for restoring The health of the mother is seriously jeopardized by match of 2 units of whole circulating maternal blood maternal shock, the health and life of the baby is also at blood volume if needed risk. The baby may become harmed as a result of Measure intake and output Enables assessment of inadequate uterine perfusion and delivery of oxygen. renal function (will decrease There is no autoregulation of the uterine blood flow; this to under 30 ml/hr with means the uterus does not have the physiological massive circulating volume structure to control blood pressure, which dictates that loss) the flow is completely related to the mother’s blood Assess vital signs (pulse, Provide baseline data on pressure. respirations, and blood maternal response to blood In severe cases, the mother may approach pressure every 15 min; loss hypovolemic shock, which is marked by a loss of apply pulse oximeter and twenty-percent of the body’s blood or fluid volume. In automatic blood pressure this circumstance, a mother would face multiple organ cuff as necessary) failure, and the life of the unborn baby would be in Assist with placement of Provides more accurate grave jeopardy. central venous pressure or data on maternal pulmonary artery catheter hemodynamic state CONDITIONS THAT CAN LEAD HYPOVOLEMIC SHOCK and blood determinations Placental abruption – caused by premature separation Measure maternal blood Provides objective evidence of the placenta from the uterus loss by weighing perineal of amount of bleeding; Uterine rupture – caused by a breach of the pads; save any tissue saturating a sanitary pad in myometrial wall passed less than 1 hr is heavy Placental previa – this is a condition where the blood loss; tissue maybe placenta is abnormally implanted on top of or near the abnormal trophoblast tissue cervix Assist with ultrasound Supplies information on Lacerations-leading to blood loss examination placental and fetal well- Infection being Retained placenta Maintain a positive attitude Supports mother-child about fetal outcome bonding Other forms of shock include: Support woman’s self- Assists problem solving, Cardiogenic shock – caused by pulmonary embolus esteem; provide emotional which is lessened by poor or cardiac disease support to woman and her self-esteem Anaphylactic shock – an amniotic fluid embolism support person Neurogenic shock – caused by uterine inversion ® If the oxygenation or perfusion of your unborn baby is seriously compromised, your baby can experience bradycardia or tachycardia, which means that there are variations in the heart rate through acceleration, deceleration, or irregular heart rate. This is one of the first signs of fetal distress.  NCM 109 – CARE OF MOTHER, CHILD, AT RISK OR WITH PROBLEMS (ACUTE & CHRONIC) THROMBOEMBOLIC DISORDERS CORTEZ, ELLYZA L. MR. ALLAN PAULO BLAQUERA, RN THROMBOPHLEBITIS – When either type occurs in the postpartum period, it tends to occur because: A woman’s fibrinogen level is still elevated from pregnancy, leading to increased blood clotting. Dilatation of lower extremity veins is still present as a result of pressure of the fetal head during pregnancy and birth, so blood circulation is sluggish. – It tends to occur most often in women who: Are relatively inactive in labor and during the early puerperium because this increases the risk of blood clot formation Have spent prolonged time in a birthing room with their legs positioned in stirrups Have preexistent obesity and a pregnancy weight gain greater than the recommended weight gain, which can lead to inactivity and lack of exercise Have preexisting varicose veins Develop a postpartal infection Have a history of a previous thrombophlebitis – Phlebitis is inflammation of the lining of a blood vessel. Are older than age 35 years or have increased Thrombophlebitis is inflammation with the formation of parity blood clots. Thrombophlebitis is classified as either superficial vein disease (SVD) or deep vein thrombosis Have a high incidence of thrombophlebitis in their (DVT). family – Superficial vein thrombosis (SVT) refers to a blood clot Smoke cigarettes because nicotine causes in a vein near the surface, deep vein thrombosis (DVT) vasoconstriction and reduces blood flow is a clot in a deep vein in the body, usually in the leg. Superficial vein thrombosis can present as pain and inflammation while deep clots can travel to the lungs and cause a pulmonary embolism. A. SUPERFICIAL VENOUS THROMBOSIS (SUPERFICIAL THROMBOPHLEBITIS) – Refers to a blood clot in a vein near the surface – Inflammation and clotting in a superficial vein, usually in SYMPTOMS OF SVT the arms and legs Pain and swelling develop rapidly in the area of – The skin over the vein becomes red, swollen, and inflammation painful o The skin over the vein becomes red and the – It most often affects the superficial veins (veins located area feels warm and is very tender just under the skin) in the legs but may also affect Because the blood in the vein is clotted, the vein feels superficial veins in the groin or in the arms like a hard cord under the skin, not soft like a normal or – Superficial venous thrombosis in the arms usually varicose veins results from having an IV. While in the legs usually o The vein may feel hard along its entire length result from varicose veins. – This involves a sudden (acute) inflammatory reaction DIAGNOSIS AND TESTS that causes the blood clot (thrombus) to adhere firmly to Ultrasound the vein wall and lessens the likelihood that it will break Venogram loose CT or MRI – Superficial veins have no surrounding muscles to Blood tests squeeze and dislodge a blood clot – Superficial venous thrombosis rarely causes a blood TREATMENT OF SVT clot to break loos (embolism) Warm compress Migratory phlebitis or Analgesic (such as aspirin or another nonsteroidal migratory thrombophlebitis is anti-inflammatory drug usually help relieve the pain) superficial venous Blood thinner medications (anticoagulants) – thrombosis that repeatedly reduce the blood’s ability to clot. They prevent the clots occurs in normal veins. It from getting bigger and prevent new clots from forming. may indicate a serious Clot busters (thrombolytics) are given to break up underlying disorder, such as blood clots. They can cause severe bleeding so they cancer of an internal organ. are only given in very serious situations. When migratory phlebitis Compression stockings these can reduce the and cancer of an internal swelling that happens after a blood clot forms in the leg. organ occur together, the The stocking are tighter near the ankle and looser near disorder is called Trousseau the top. This helps the keep the blood from pooling and syndrome. clotting  Filters – if the patient cannot take medications, they Self-care – elevate the leg; apply heating pad for 20 may have a small filter inserted into a large vein in the minutes every 2 hours; keep walking, physical work, abdomen called the vena cava. If the blood clot breaks and lifting to a minimum off, this will reduce the chance of it travelling to the lungs. De B. DEEP VEIN THROMBOSIS (DVT) – Occurs when a blood clot (thrombus) forms in one or more deep veins in the body, usually in the legs SYMPTOMS OF DVT – This can cause leg pain or swelling. They can occur Leg swelling without noticeable symptoms Leg pain, cramping or soreness that often starts in the – These clots usually develop in the lower leg, thigh, or calf pelvis, but they also occur in the arm Change in skin color on the leg – such as red or purple, – DVT can be serious become blood clots in the veins depending on the color of your skin can break loose A feeling of warmth on the affected leg – The clots can travel through the bloodstream and get Veins that are swollen, red, hard, or tender to the touch stuck in the lungs, blocking blood flow (pulmonary that you can see embolism) – When DVT and pulmonary embolism occur together, WARNING SIGNS OF PULMONARY EMBOLISM it’s called venous thromboembolism (VTE) Sudden shortness of breath Chest pain or discomfort that worsens when you take a deep breath or when you cough Feeling lightheaded or dizzy Fainting Rapid pulse Rapid breathing Coughing up blood TREATMENT OF DVT Blood thinners (Thrombolytics) – most common medications used to treat DVT. They cut the blood’s ability to clot. A patient may need to take them for 6 months. If the symptoms are severe or the clot is very large, the doctor may give the patient a strong medicine to dissolve it. They have serious side effects like severe bleeding. That’s why they’re not prescribed very often. Inferior vena cava (IVC) filter – a doctor may insert a small, cone-shaped filter inside the inferior vena cava (largest vein in the body). The filter can catch a large clot before it reaches the lungs Compression stockings – the pressure from the stockings prevents blood from pooling in the vein C. PULMONARY EMBOLISM – A pulmonary embolus is obstruction of the pulmonary o Because of the seriousness of this condition, a artery by a blood clot woman with a pulmonary embolism commonly is – It usually occurs as a complication of thrombophlebitis transferred to an intensive care unit for continuing when a blood clot moves from a leg vein to the care. pulmonary artery. SIGNS AND SYMPTOMS Sudden, sharp chest pain Tachypnea Tachycardia orthopnea (inability to breathe except in an upright position) cyanosis (the blood clot is blocking both blood flow to the lungs and return to the heart) THERAPEUTIC MANAGEMENT A woman needs oxygen administered immediately and is at high risk for cardiopulmonary arrest. o Her condition is extremely guarded until the clot can be lysed or adheres to the pulmonary artery wall and is reabsorbed.  NCM 109 – CARE OF MOTHER, CHILD, AT RISK OR WITH PROBLEMS (ACUTE & CHRONIC) PUERPERAL INFECTIONS CORTEZ, ELLYZA L. MR. ALLAN PAULO BLAQUERA, RN PUERPERAL INFECTIONS Placenta previa – Infection of the reproductive tract in the postpartal Hemorrhage period Cesarean delivery – After rupture, pathogens can begin to invade; the risk of infection grows even greater is tissues edema and A. ENDOMETRITIS trauma are present – Infection of the endometrium (lining of the uterus) – It usually begins as only a local infection – Bacteria gain access to the uterus through the vagina – It has the potential to spread to the peritoneum and enter the uterus either at the time of birth of during (peritonitis) or the circulatory system (septicemia), the postpartal period conditions that can be fatal in a woman whose body is – This may occur with birth, but the infections is usually already stressed from childbirth associated with chorioamnionitis and a cesarean birth – Organisms commonly cultured postpartally: o Group b streptococci ASSESSMENT o Staphylococci A benign temperature elevation may occur on the first o Aerobic gram-negative bacilli (Escherichia coli) postpartal day, particularly if a woman is not drinking – Management: use of an appropriate antibiotic after enough fluid culture and sensitivity testing of the isolated organism The fever of endometritis usually manifests itself on the third or fourth postpartal day CONDITIONS THAT INCREASES A WOMAN’S RISK FOR o Suggesting that much of the invasion occurred POSTPARTAL INFECTION during labor or birth (consistent with the time it takes for infectious organisms to grow) Risk Factor Basis for Risk o Infection is suspected, instead, in postpartal Rupture of the membranes Bacteria may have started women who have a temperature over 100.4°F more than 24 hours before to invade the uterus while (38°C) for two consecutive 24-hour periods. birth the fetus was still in the Depending on the severity of the infections, a woman utero may have accompanying chills, loss of appetite, and Retained placental The tissue necroses and general malaise. fragments within the uterus serves as an excellent bed o The uterus usually is not well contracted and is for bacterial growth painful to touch. May feel strong afterpains Postpartal hemorrhage The woman’s general o Lochia is usually dark brown and has a foul condition is weakened odor. It may be increased in amount because Preexisting anemia The woman’s general of poor uterine inovulation condition is weakened If the infection is accompanied by high fever, lochia Prolonged and difficult Trauma to the tissue may may be scant or absent. labor, particularly with leave lacerations or A sonogram may be prescribed to confirm the instruments births fissures for easy portals of presence of placental fragments that could be a entry for infection possible cause of the infection. Internal fetal heart Contamination may have monitoring electrode been introduced with THERAPEUTIC MANAGEMENT placement of the scalp electrodes Administration of an appropriate antibiotic, such as clindamycin (Cleocin), as determined by the culture Local vaginal infection A direct spread of infection present at the time of birth has occurred An oxytocic agent such as methylergonovine may also be prescribed to encouraged uterine contraction Uterus explored after birth The infection was for a retained placenta or introduced with exploration Urge the woman to drink additional fluid to combat the abnormal bleeding site fever If strong pains and abdominal discomfort are present, PREDISPOSING FACTORS ask if she needs an analgesic for pain relief Sitting on a semi-Fowler’s position or walking Low host resistance encourages lochia drainage by gravity and helps Multiplication of organisms in the devitalized tissue prevent polling of infected secretions usually starts the first two days following delivery If the infection is limited to the endometrium, the Introduction of organisms from outside course of infection with be about 7 to 10 days Increased prevalence of organisms resistance to Danger: it can lead to tubal scarring and interference antibiotics with future infertility ANTENATAL FACTORS B. INFECTION OF THE PERINEUM Malnutrition and anemia – If a woman has a suture line on her perineum from an Preterm labor episiotomy or a laceration repair, a ready portal of entry Premature rupture of membranes exists for bacterial invasion. Prolonged rupture of membranes >18 hours Chronic debilitating illness ASSESSMENT Infections of the perineum usually remain localized INTANATAL FACTORS They are revealed by symptoms similar to those of Repeated vaginal examination any suture line infection, such as pain, heat, and a Traumatic operative delivery feeling of pressure Dehydration and ketoacidosis during labor Retained bits of placental tissue or membrane  The woman may or may not have an elevated THERAPEUTIC MANAGEMENT temperature depending on the systemic effect and Peritonitis is often accompanied by a paralytic ileus (a spread of the infection blockage of inflamed intestines). Inspection of the suture line will reveal inflammation o This requires insertion of a nasogastric tube to One or two stitches may have sloughed away, so an prevent vomiting and to rest the bowel. area of the suture line is open with purulent drainage Intravenous fluid or total parenteral nutrition will then present be necessary. A woman will need analgesics for pain relief and intravenous antibiotics to treat the infection. Peritonitis can interfere with future fertility because it can leave scarring and adhesions in the peritoneum, which separate the fallopian tubes from the ovaries to the extent that ova can no longer easily enter the tubes. THERAPEUTIC MANAGEMENT Typically, either a systemic or topical antibiotic is ordered even before the culture report is returned An analgesic may be prescribed to alleviate discomfort It may be necessary to remove perineal sutures to open the area and allow for drainage Sitz baths, moist warm compresses, or Hubbard tank treatments may be prescribed to hasten drainage and cleanse the area Remind the woman to change perineal pads frequently o Because they are contaminated by drainage, if left in place for too long, they might cause vaginal contamination or reinfection C. PERITONITIS – Infection of the peritoneal cavity, usually occurs as an extension of endometritis – It is one of the gravest complications of childbearing – A major cause of death from puerperal infection – The infection spreads from the uterus through the lymphatic system or directly through the fallopian tubes or uterine wall to the peritoneal cavity – An abscess may form in the cul-de-sac of Douglas because this is the lowest point of the peritoneal cavity and gravity causes infected material to localize there ASSESSMENT Symptoms o Rigid abdomen o Abdominal pain o High fever o Rapid pulse o Vomiting o Appearance of being acutely ill When assessing the abdomen of a postpartal woman, be sure to note not only that her uterus is well contracted but also that the remainder of her abdomen is soft because the occurrence of a rigid abdomen (i.e., guarding) is one of the first symptoms of peritonitis  NCM 109 – CARE OF MOTHER, CHILD, AT RISK OR WITH PROBLEMS (ACUTE & CHRONIC) PREMATURITY DAYAG, CEE JAY MARIE G. MR. ALLAN PAULO BLAQUERA, RN PREMATURITY PRETERM INFANT – A baby born before 37 weeks of pregnancy is – A preterm infant is traditionally defined as a live-born considered premature or born too early. infant born before the end of week 37 of gestation – Things that may cause premature labor are: – Most preterm infants need intensive care from the o Being pregnant with more than one baby moment of birth to give them their best chance of o Bleeding or other problems with the uterus survival without neurologic aftereffects because they o Stress are more prone than others to hypoglycemia and o Infection in the uterus or elsewhere in the body intracranial hemorrhage – Lack of lung surfactant, because this does not form until Prematurity is define as: about the 34th week of pregnancy, makes them Early term infants. Babies born between 37 weeks extremely vulnerable to respiratory distress syndrome and 38 weeks, 6 days – No matter what their weight, the initial assessment Late preterm infants. Babies born between 34 weeks needs to differentiate healthy preterm babies from SGA and 36 weeks, 6 days babies (who also may have a low birth weight but have Very preterm. Babies born at or below 32 weeks more possibility of being unhealthy and so require more Extremely preterm. Babies born at or below 28 weeks help to adjust to extrauterine life) – In contrast to an SGA infant, a preterm infant appears RISK FACTORS immature and has a low birth weight but is well Having had a previous preterm labor or birth proportioned for age because the baby appears to have been doing well in utero. Getting pregnant within a short time (less than a year) after having had a baby CONTRAST BETWEEN SGA AND PRETERM INFANTS Carrying twins, triplets, or more babies at one time Having an abnormal cervix or uterus CHARACTERISTIC SGA PRETERM Being younger than 16 or older than 35 Gestational Age 24-44 wk