ATI Comprehensive Maternal & Newborn Nursing PDF

# UNIT EIGHT ## Maternal and Newborn Nursing ### **The Comprehensive NCLEX-RN® Review** ### **SECTION 1** **Female Reproductive System** **Reproduction** - **Reproductive Organs** - Ovaries - Fallopian tubes - Uterus - Cervix - Vagina - **Fertilization and Fetal Development...

# UNIT EIGHT ## Maternal and Newborn Nursing ### **The Comprehensive NCLEX-RN® Review** ### **SECTION 1** **Female Reproductive System** **Reproduction** - **Reproductive Organs** - Ovaries - Fallopian tubes - Uterus - Cervix - Vagina - **Fertilization and Fetal Development** - **Conception** (i.e., fertilization): union of sperm and ovum - **Conditions necessary for fertilization** - Mature egg and sperm - Timing - Lifetime of ovum is 24 hr. - Lifetime of sperm in female genital tract is 72 hr. - Menstruation begins approximately 14 days after ovulation if conception has not occurred. - Vaginal and cervical secretions - Less acidic during ovulation (sperm cannot survive in a highly acidic environment) - Thinner during ovulation (sperm can penetrate more easily) - **Process of fertilization** (7 to 10 days) - Ovulation occurs. - Ovum travels to fallopian tube. - Sperm travels to fallopian tube. - One sperm penetrates the ovum. - Zygote forms (i.e., fertilized egg). - Zygote migrates to uterus. - Zygote implants in uterine wall. - Progesterone and estrogen are secreted by the corpus luteum to maintain the lining of the uterus and prevent menstruation until the placenta starts producing these hormones. (Progesterone is a thermogenic hormone that raises body temperature, an objective sign that ovulation has occurred.) - **Placental development** - **Chorionic villi** - Secrete human chorionic gonadotropin (hCG), which stimulates production of estrogen and progesterone from the corpus luteum. - Production of hCG begins on the day of implantation and can be detected by day 6. - Burrow into the endometrium, forming the placenta. - **Placental hormones** - hCG - Human chorionic somatomammotropin (hCS): acts as growth hormone and insulin antagonist - Estrogen and progesterone - **Fetal membranes develop and surround the fetus.** - **Amnion**: inner membrane - **Chorion**: outer membrane - **Umbilical cord** - Two arteries carry deoxygenated blood to the placenta. - One vein carries oxygenated blood to the fetus. - No pain receptors - Encased in Wharton’s jelly (thick substance that surrounds the umbilical cord and acts as a buffer, preventing pressure on the vein and arteries in the umbilical cord) - Covered by chorionic membrane - **Amniotic fluid** - Replaced every 3 hr - 800 to 1,200 mL at end of pregnancy - Functions: temperature regulation, protection, and promotes musculoskeletal development of the fetus ### **SECTION 2** **Pregnancy** - **Prenatal Period** - Begins with conception and ends before birth. - **Anatomy and Physiology** - Female anatomy: hormones, ovulation, organs - Male anatomy: sperm, vas deferens, seminal fluid - Fetal/maternal circulation: fetal and maternal blood do not mix - **Psychological and Physiological Adaptations of Pregnancy** - **Ambivalence** - **Accepting** - **Preparing for birth** ### **SECTION 3** **Complications of Pregnancy** #### **Medical Problems** - Preexisting conditions may complicate pregnancy. - Some medical conditions develop during pregnancy and cause complications. - **Cardiac Disease** - **Contributing Factors** - Preexisting heart condition - Increased maternal plasma volume - **Greatest Risks for Heart Failure** - End of second trimester (28 to 32 weeks) - During labor - After delivery (first 48 hr) - **Manifestations** - **Subjective data** - Dizziness - Shortness of breath - Weakness - Fatigue - Chest pain on exertion - Anxiety - **Objective data**: physical assessment findings - Arrhythmias - Irregular heart rate - Tachycardia - Heart murmur - Distended jugular veins - Cyanosis of nails or lips - Pallor - Generalized edema - Diaphoresis - Increased respirations - Moist, frequent cough - Hemoptysis - Crackles at base of lungs - Intrauterine growth restriction - Decreased amniotic fluid - FHR with decreased variability - **Laboratory and Diagnostic Testing** - Laboratory tests - Hgb - Hct - WBC - Chemistry profile - Sedimentation rate - Maternal ABGS - Clotting studies - Other diagnostic procedures - Echocardiogram - Holter monitoring - Chest x-ray - Ultrasound - Pulse oximetry - NST - Biophysical profile - **Collaborative Care** - **Nursing Interventions** - Assess for signs and symptoms of fatigue, anemia, weight gain more than 1 to 2 lb/week, pulmonary edema, peripheral edema, palpitations, tachycardia, angina. - Prevent infection. - Provide nutritional counseling; well-balanced diet with iron and folic acid. - **Medications**: Pharmacological management is determined by the client’s cardiac diagnoses and clinical presentation. - Propranolol: beta blocker; used to treat tachyarrhythmias and to lower maternal blood pressure - Ampicillin antibiotic; prophylaxis given to prevent endocarditis - Heparin sodium: anticoagulant used in treating clients with pulmonary embolus, deep-vein thrombosis, prosthetic valves, cyanotic heart defects, and rheumatic heart disease - Digoxin: cardiac glycoside; used to increase cardiac output during pregnancy, and may be prescribed if fetal tachycardia is present - Anticoagulant therapy (heparin) - Teach bleeding precautions - Report any bleeding - **Hypertension in pregnancy:** Hypertensive disease in pregnancy is divided into clinical subsets: gestational hypertension; mild and severe preeclampsia; eclampsia; hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome. - **Vasospasm** contributing to poor tissue perfusion is the underlying mechanism for the signs and symptoms of pregnancy hypertensive disorders. - **Gestational hypertension (GH)** - Begins after the 20th week of pregnancy. - Presents with elevated blood pressure of 140/90 mm Hg or greater on two occasions, at least 4 hr apart, within 1 week. - There is no proteinuria. - Blood pressure returns to baseline by 6 weeks postpartum. - **Mild preeclampsia** is GH with the addition of proteinuria of 1 to 2+. - **Severe preeclampsia** - Blood pressure 160/110 mm Hg or greater on two separate occasions 6 hr apart on bed rest - Proteinuria greater than 3+ (dipstick) - Oliguria - Serum creatinine greater than 1.1 mg/dL - Cerebral or visual disturbances (e.g., headache and blurred vision) - Hyperreflexia with possible ankle clonus - Pulmonary or cardiac involvement - Extensive peripheral edema - Hepatic dysfunction (elevated liver function tests) - Epigastric and right upper-quadrant pain - Thrombocytopenia - **Eclampsia** - Severe preeclampsia, plus seizure activity - Usually preceded by persistent headache, blurred vision, severe epigastric or right upper quadrant abdominal pain, and altered mental status - **HELLP syndrome** is a variant of GH in which hematologic conditions coexist with severe preeclampsia involving hepatic dysfunction. HELLP syndrome is diagnosed by laboratory tests, not clinically. - **H:** hemolysis resulting in anemia and jaundice - **EL:** elevated liver enzymes resulting in elevated ALT and AST, epigastric pain, and nausea and vomiting - **LP:** low platelets (less than 100,000/mm³), resulting in thrombocytopenia, abnormal bleeding and clotting time, bleeding gums, petechiae, and possibly DIC - **Contributing Factors** - No single profile identifies risks for gestational hypertensive disorders, but some high risks include: - Maternal age younger than 20 or older than 40 - First pregnancy - Morbid obesity - Multifetal gestation - Chronic renal disease - Chronic hypertension - Familial history of preeclampsia - Diabetes mellitus - Rh incompatibility - Molar pregnancy - Previous history of GH - **Manifestations of Preeclampsia** (vary depending upon severity) - **Hypertension** - **Proteinuria:** 1+ or greater on dipstick, or 300 mg in 24-hr urine specimen - **CNS irritability:** headaches, hyperreflexia, positive ankle clonus - **Visual disturbances:** scotoma, blurred or double vision - **Decreased liver perfusion:** elevated liver enzyme (LDH, AST, ALT), epigastric or right-upper quadrant pain - **Decreased renal perfusion:** proteinuria, oliguria - **Decreased plasma colloid osmotic pressure:** elevated Hct, tissue edema with weight gain, pulmonary edema - **Elevated plasma uric acid** - **Laboratory and Diagnostic Testing** - Blood pressure elevation - Urine studies: urinalysis for proteinuria, 24-hr urine protein - Liver enzymes, serum creatinine, BUN, uric acid - **Collaborative Care** - **Nursing Interventions** - Monitor blood pressure.. - Administer medications. - Discuss nutrition (balanced diet; 60 to 70 g protein, 1,200 mg calcium, 600 mcg folic acid; limit salty foods; eat foods with roughage; avoid alcohol and tobacco; and limit caffeine intake). - Perform maternal assessments: daily weight, I&O, reflexes, CNS. - Obtain fetal assessments: serial ultrasound, Doppler blood flow analysis; NST, CST, BPP; fetal kick count. - Encourage bed rest on left side. - Initiate seizure precautions (preeclampsia/eclampsia). - Provide quiet environment: private room not next to nurses’ station, dim lights. - Monitor for HELLP and DIC (severe preeclampsia/eclampsia). - **Medications** - **Antihypertensive medications** to keep blood pressure less than 160/110 mm Hg - Magnesium sulfate: anticonvulsant - Administer IV magnesium sulfate, which is the medication of choice for prophylaxis or treatment. Reduces seizure threshold (depression of the CNS); secondary side effect is decreased blood pressure as it relaxes smooth muscles. - **Nursing Interventions** - Use an infusion control device to maintain a regular flow rate. - Inform the client that she may initially feel flushed, hot, and sedated with the magnesium sulfate bolus. Nausea/vomiting may occur. - Monitor vital signs; blood pressure, pulse, respirations; CNS; level of consciousness, headache or visual disturbances, reflexes; renal perfusion; output (of indwelling urinary catheter); epigastric pain; FHR. - Place the client on fluid restriction of 100 to 125 mL/hr, and maintain a urinary output of 30 mL/hr or greater. - Monitor the client for signs of magnesium sulfate toxicity. - Absence of patellar deep tendon reflexes - Urine output less than 30 mL/hr - Respirations less than 12/min - Decreased level of consciousness - Cardiac dysrhythmias - **Diabetes Mellitus** - **Types** - **Pregestational diabetes mellitus:** Client had diabetes prior to pregnancy. - **Gestational diabetes mellitus:** An impaired tolerance to glucose with the first onset or recognition during pregnancy. The ideal blood glucose level during pregnancy is 70 to 110 mg/dL. Client develops diabetes mellitus during pregnancy, usually in the second or third trimester. - **Contributing Factors** - Obesity - Maternal age older than 25 years - Family history of diabetes mellitus - Previous delivery of an infant who was large or stillborn - **Manifestations** - **Hypoglycemia** (nervousness, headache, weakness, irritability, hunger, blurred vision, tingling of mouth or extremities) - **Hyperglycemia** (thirst, nausea, abdominal pain, frequent urination, flushed dry skin, fruity breath) - **Laboratory Testing and Diagnostic Procedures** - Routine urinalysis with glycosuria - **Glucose tolerance test** (50 g oral glucose load, followed by plasma glucose analysis 1 hr later performed at 24 to 28 weeks of gestation-fasting not necessary; a positive blood glucose screening is 140 mg/dL or greater; additional testing with a 3-hr glucose tolerance test is indicated) - A 3-hr glucose tolerance test (following overnight fasting, avoidance of caffeine, and abstinence from smoking for 12 hr prior to testing; a fasting glucose is obtained, a 100 g glucose load is given, and serum glucose levels are determined at 1, 2, and 3 hr following glucose ingestion) - Monitor HbA1c. - Monitor for ketones. - BPP to ascertain fetal well-being - NST to assess fetal well-being - Amniocentesis with alpha-fetoprotein - **Collaborative Care** - **Risks** to newborn increase with poor glucose control. - Congenital anomalies - Spontaneous abortions - Macrosomia: birth trauma and dystocia - Death - Hypoglycemia after birth - **Nursing Interventions** - Diet - Exercise - Blood glucose monitoring - Insulin if medication required - **Medications** - Oral hypoglycemic, such as glyburide, is occasionally used for gestational diabetes. - May require insulin - Insulin needs decrease during the first trimester. - Insulin needs increase during the second and third trimester due to an increase in hormones such as hCS (insulin antagonist). - **Hyperemesis gravidarum:** Excessive pregnancy-related nausea and/or vomiting. Hospitalization may be necessary because of dehydration and weight loss. - Begins first or second month of pregnancy - **Contributing factors** - High levels of human chorionic gonadotropin (hCG) and estrogen - Decreased gastric motility and gastroesophageal reflux - **Manifestations** - Loss of 5% or more of prepregnancy body weight - Dehydration, causing ketosis and constipation - Nutritional deficiencies - Metabolic imbalances - **Collaborative Care** - **Nursing Interventions** - Assess psyche; refer as needed. - Assess weight. - Assess for dehydration, electrolyte imbalance, and metabolic alkalosis. - Monitor I&O. - Administer IV fluids. - Small meals per client preference. - **Medications** - Antiemetics such as ondansetron - Vitamin B6, no more than 100 mg daily used solo or in combination with doxylamine - **Therapeutic Measures** - Acupressure; relaxation techniques - **Client Education** - Nausea and vomiting usually peak between 2 and 12 weeks of pregnancy and go away by the second half of pregnancy. - Eat small, frequent meals; eating dry foods such as crackers may help relieve uncomplicated nausea. - Increase fluid intake to prevent dehydration; teach to increase fluids during the times of the day when the client feels the least nauseated; seltzer, ginger ale, or other sparkling waters may be helpful. - **Placental and Cervical Problems** - **Abruptio Placentae** - **Contributing Factors** - Trauma - Preeclampsia - Multiparity - Cocaine use - **Placenta Previa** - **Contributing Factors** - Placenta implants completely or partially over cervical os. ### **SECTION 4** **Labor and Delivery** - Labor and delivery include the period during which the baby and placenta are delivered and up to 1 to 2 hr after delivery. - **Labor and delivery processes**-Six major factors: "P's" of labor and delivery process. - **Psyche**-the mother’s psychological response to labor - **Powers**-uterine contractions - **Uterine contractions:** act to dilate and efface the cervix - **Frequency:** From the beginning of one contraction to the beginning of the next contraction. Contraction frequency closer than 2 min is considered hyperstimulation. - **Duration:** From the beginning to end of the same contraction. Contraction duration greater than 90 seconds is considered hyperstimulation. - **Intensity:** Strength of the uterine contraction. Can only be accurately measured with an internal uterine pressure catheter (IUPC). - **Effacement:** Shortening and thinning of the cervix. The goal is 100% effacement. - **Dilation:** Opening of the cervix. The diameter of the cervix ranges from o cm (closed) to 10 cm (fully dilated). - **Passenger**-the fetus and placenta - **Presentation**-the part of the fetus that enters the pelvic inlet first - The three primary presentations are cephalic, breech, and shoulder. Breech and shoulder presentations are indications for cesarean birth. - **Station:** the relationship of the presenting part to the maternal ischial spines that measures the degree of descent of the fetus - Negative stations are above ischial spines (-1, -2). - Zero station is at the ischial spines, or engaged (o). - Positive stations are below the ischial spines (+1, +2, +3). Delivery is typically sooner. - **Position:** Relationship of presenting part (e.g., occiput, mentum, sacrum) to the maternal pelvic inlet. Clients with fetus in persistent occiput posterior position (POP) have increase back (labor) pain and longer labors. - **Passageway:** the birth canal, pelvis, cervix, pelvic floor and vagina - **Cephalopelvic disproportion:** When the fetus has a head size, shape, or position that does not allow for passage through the pelvis. This can also occur secondary to maternal pelvic structure or associated problems. - **Manifestations of False vs. True Labor** ### **SECTION 5** **Complications During Labor and Delivery** - **Preterm labor:** uterine contractions with cervical changes that occur between 20 and 37 weeks of gestation - **Contributing Factors** - **Demographic factors** - Age less than 15 and greater than 35 - Low socioeconomic status - **Biophysical factors** - Previous preterm labor or birth - Multifetal pregnancy - Second trimester bleeding - Infection - **Behavioral factors** - Lack of prenatal care - Poor nutrition - Substance abuse - **Nursing Interventions** - Obtain vaginal swab for fetal fibronectin testing. - Assist with collection of cervical cultures. - Activity restriction (e.g., bed rest with bathroom privileges, left-lateral position). - Ensure hydration. - Assess for signs of infection: UTI, vaginal drainage including odor. - Monitor maternal vital signs including temperature. - Monitor FHR and contraction pattern. - Administer tocolytic medications and betamethasone. - **Fetal Distress** - FHR baseline below 110 or above 160 - Absent FHR variability - Category III FHR pattern (See the table on the FHR Classification System in this unit.) - Fetal blood pH less than 7.2 - **Contributing Factors** - **Uteroplacental insufficiency** - **Acute uteroplacental insufficiency** - Excessive uterine activity associated with use of oxytocin - Maternal hypotension: epidural, vena caval compression, supine position, hemorrhage - Placental separation: abruptio, placentae previa - **Chronic uteroplacental insufficiency** - Gestational hypertension - Chronic hypertension - Smoking or illicit drug use - Diabetes mellitus - Postmaturity - **Nursing Interventions** - Stop oxytocin. - Administer oxygen at 8 to 10 L/min by nonrebreather face mask. - Reposition client. - Increase IV fluids. - Notify the provider. - Perform fetal scalp stimulation or vibroacoustic stimulation per protocol. - **Umbilical Cord Problems** - **Contributing Factors** - Cord compression: pressure on the umbilical cord during pregnancy, labor, or delivery that reduces blood flow from the placenta to the fetus - Causes: abnormal presentation, inadequate pelvis, presenting part at high station, multiple gestations, prematurity, premature rupture of membranes, and/or polyhydramnios - Complications: fetal asphyxia - Nuchal cord (cord around neck) - Prolapsed cord - **Nursing Interventions** - **Prolapsed cord** - Call for assistance immediately. - Notify care provider. - Use sterile-gloved hand, insert two fingers into the vagina, and apply finger pressure on either side of the cord to the fetal presenting part to elevate it off of the cord. - Reposition in a knee-chest or Trendelenburg position. - Administer oxygen at 8 to 10 L/min by nonrebreather face mask. - If cord is protruding from the vagina, wrap it loosely in a sterile saline-soaked towel. - Closely monitor FHR for variable decelerations and bradycardia. - Prepare for immediate birth: vaginal or cesarean. - **Cord compression** - Position change is priority. - Administer oxygen at 8 to 10 L/min by nonrebreather face mask. - Prepare to assist with amnioinfusion. - **Emergency Childbirth** - **Contributing Factors** - Precipitous delivery - **Nursing Interventions** - Encourage mother to pant, unless the fetus is in breech presentation. - Support the perineum. - Rupture the membranes if they have not yet ruptured. - Feel for the cord around the neonate's neck, and gently slip it over his head. - Keep the neonate dry and warm. - Do not cut the cord. - Deliver the placenta. Expect a gush of blood and a lengthening of the cord. - Save the placenta. - Massage fundus. Encourage breastfeeding to contract uterus. - **Amniotic Fluid Emboli** (anaphylactoid syndrome of pregnancy) - Rupture in the amniotic sac or maternal uterine veins accompanied by a high intrauterine pressure. - Amniotic fluid enters maternal circulation and travels to and obstructs pulmonary vessels, which causes respiratory distress and circulatory collapse. - **Manifestations** - Respiratory distress (e.g., restlessness, cyanosis, dyspnea, pulmonary edema, respiratory arrest) - Circulatory collapse (e.g., tachycardia, hypotension, shock, cardiac arrest) - Hemorrhage (e.g., bleeding from incisions and venipuncture sites, petechiae and ecchymosis, uterine atony) - Seizure activity - **Nursing Interventions** - Administer 10 L oxygen via face mask. - Prepare client for intubation. - Initiate and/or assist with CPR. - Administer IV fluids. - Administer blood or blood products. - Prepare for an emergency birth. - Prepare for an emergency cesarean birth if fetus is not yet delivered. - **Dystocia:** Dysfunctional, Abnormal Labor - **Contributing Factors** - Dysfunction of uterine contractions - Abnormal position - Fetopelvic disproportion - Maternal exhaustion - Macrosomia - **Nursing Interventions** - Assess fetus and status of labor. - Encourage to void and ambulate regularly. - Assist in positioning and coaching during contractions. - Prepare for a possible forceps, vacuum-assisted, or cesarean birth. - Shoulder dystocia: McRoberts maneuver and suprapubic pressure (not fundal pressure). ### **SECTION 6** **Postpartum** - **Postpartum/Puerperium** - Approximate duration: 6 weeks - Main goal: prevent postpartum hemorrhage - Greatest risks: hemorrhage, shock, and infection - Includes physiological and psychological adjustments - Changes after delivery of the placenta: hormones (e.g., estrogen, progesterone, and placental enzyme insulinase [hCS]) decrease, causing decreased blood glucose (hCS), diaphoresis, and diuresis (estrogen). Oxytocin increases (contractions, breast milk, and involution). - **Physical Assessment** - Vital signs, Hgb, Hct, CBC, estimated blood loss in delivery - Pain - Monitor location, intensity of pain. - Examine location of pain. - Implement nonpharmaceutical measures. - Implement pharmaceutical measures. - Consider safety of medications related to breastfeeding. - Hydrocodone/acetaminophen - Ibuprofen - PCA such as morphine sulfate or fentanyl - Breasts - **Colostrum** - Transitions to milk 48 to 96 hr - High nutrition - Milk production occurs about day 2 or 3 - Sucking stimulates uterine contractions, promotes uterine involution and increased milk production. - Supplementing with formula may decrease production. - Breast milk actively supports the immune system. Protects against many bacterial, viral, and protozoal infections; IgA is major immunoglobulin in human milk that provides passive immunity. - **Engorgement** - About 48 hr postpartum - May cause slight rise in temperature - **Nonlactating clients** - Avoid nipple stimulation - Cold compress - Pain medication - Supportive bra - **Lactating clients** - Manually express some milk to facilitate latch - Frequent feeding or pumping - Warm shower - Breast massage - Supportive bra - **Uterus** - Involution - Firm - Fundus near umbilicus after delivery - Descends approximately 1 cm/day - Breastfeeding enhances - Full bladder impedes involution - Subinvolution - Massage - Frequent voiding - Oxytocin - **Lochia:** Note color, amount (scant to moderate), presence of clots, and odor (fleshy). - **Color** - **Rubra:** bright red, may contain small clots, transient flow increases during breastfeeding and upon rising. Lasts 1 to 3 days. - **Serosa:** brownish red or pink. Lasts from day 4 to day 10. - **Alba:** yellowish, white creamy color. Lasts from day 11 up to and beyond 6 weeks postpartum. - Teach about return of menses. - Ovulation may occur prior to first menses. - Nonlactating client: 6 to 8 weeks. - Breastfeeding exclusively: may be up to 6 months. - Need for birth control. - **Perineum** - **Assess perineum using REEDA** : - Redness - Edema - Ecchymosis - Drainage - Approximation - **Comfort and healing** - Cold compress first 24 hr - Sitz bath - Positioning - Perineal hygiene - Kegel exercises - Medication - **Bladder** - Potential problem due to effects of anesthesia and hormones. - Distended bladder increases potential for uterine atony and bleeding. Fundus will deviate to the side and above umbilicus. - Assist with frequent urination. - Provide noninvasive measures to promote urination. - Perform bladder scan. - Catheterize if retention persists. - **Bowel** - Bowel movement in 1 to 2 days. - Assess for hemorrhoids. - Promote fiber, activity, fluids. - Administer stool softener. - Provide sitz bath. - Apply topical anesthetic. - **Edema and DTRS** - Assess for pitting edema. - Excessive use of oxytocin increases risk for edema. - 2+ DTRs normal. - **Deep-Vein Thrombosis** - Prevention is key: early ambulation. - Assess for pain, redness, or swelling of lower extremities. - **Infection** - Temperature normally elevated to 38° C (100.4° F) first 24 hr after delivery. - WBCs may be elevated to 20,000 to 25,000/mm³ the first 10 to 14 days. - Do not assume "normal." - Assess possible sources of infection. - **Psychologic Adaptations** - Support systems - Self-concept - **Bonding** - Initial contact within 30 to 60 min after birth - Client exploration of infant - Fingertips, then palms - Extremities, then trunk - En face - **Collaborative Care** - Minimize pain, fatigue, and hunger to enhance bonding. - Describe newborn behaviors. - **Maternal Role Adaptation** - **PHASES OF MATERNAL ADJUSTMENT** - **Taking in:** 24 to 48 hr after birth: dependent, passive; focuses on own needs; excited, talkative - **Taking hold:** Second to tenth day postpartum, or up to several weeks: focuses on maternal role and care of newborn; eager to learn; may develop blues - **Letting go:** Focuses on family and individual roles - **Postpartum Blues and Depression** ### **SECTION 7** **Complications During Postpartum** - **Hemorrhage:** blood loss of greater than 500 mL with vaginal delivery or greater than 1,000 mL with cesarean birth - **Contributing Factors** - Uterine atony - Lacerations and hematomas - Complications during pregnancy (e.g., placenta previa, abruptio placentae) - Complications during labor (e.g., prolonged labor, rapid labor, administration of magnesium sulfate, use of forceps, retained placenta) - Overdistended uterus (e.g., macrosomia, multiple fetuses) - Coagulopathies (DIC) - **Manifestations** - Saturation of one pad or more in 15 min - Large clots (uterine atony) or spurting of bright red blood (cervical or vaginal laceration) - Formation of hematomas - Boggy uterus (uterine atony) - Persistent lochia rubra beyond day 3 (retained placental fragments) - Change in level of consciousness - Signs and symptoms of shock - **Nursing Interventions ** - Assess source of bleeding. - Fundus (massage if boggy) - Perineum (laceration, episiotomy site, or hematomas: notify provider) - Monitor vital signs and oxygen saturation. - Assess bladder. - Maintain or initiate isotonic IV fluids. - Administer oxytocin. - Administer other medications as needed (e.g., methylergonovine, misoprostol, carboprost tromethamine). - **Rh Incompatibility** - **Nursing Interventions** - Observe newborn for hyperbilirubinemia. - Teach mother about Rh, RhoGAM. - Prevents, does not reverse, formation of antibodies - Given prenatally with any invasive procedure at 28 weeks and after delivery - Administer RhoGAM. - Rho(D) immune globulin - IM - Given within 72 hr after delivery - **Thromboembolic Disorder** - **Contributing Factors** - Venous stasis and hypercoagulation - Immobility - Pelvic pressure during labor/delivery - History of thrombosis, varicosities, heart disease - **Manifestations** - Pain, heat, redness, swelling in lower leg or extremity - **Nursing Interventions** - Assess extremities including peripheral pulses, measuring and comparing circumferences of both legs. - Homan’s sign is not recommended. - Venous Doppler to rule out DVTs. If DVT is suspected: - Bed rest and analgesia - Elevation of affected extremity - Antithrombolytic stockings - Anticoagulant therapy - **Puerperal Infections** (endometritis, mastitis, and wound infections) - **Elevated temperature of at least 38° C (100.4° F) for 2 or more consecutive days, excluding the first 24 hr.** - **Endometritis** usually begins on the second to fifth day postpartum. - More common after cesarean birth - Pelvic pain, uterine tenderness, foul smelling or profuse lochia, plus fever, tachycardia, elevated WBC and RBC sedimentation rate - **Mastitis** usually unilateral occurring 2 to 4 weeks after delivery. - Symptoms include chills, fever, malaise, and local breast tenderness and erythema. ### **SECTION 8** **Newborn** - **Neonatal Period: From Birth Through 28 Days** - **Initial Care: immediately after birth** - **Airway, Breathing, Circulation (ABCS)** - **Thermoregulation** - **Umbilical Cord** - **Inspect** for two arteries and one vein. Observe for any bleeding from the cord, and ensure that the cord is clamped securely to prevent hemorrhage. - **Apgar** - Assess at 1 and 5 min - **Apgar: Five Categories** - **Heart Rate** - **Respiratory Effort** - **Muscle Tone** - **Reflex Irritability** - **Color** - **Nursing Interventions** - Observe newborn for hyperbilirubinemia. - Teach mother about Rh, RhoGAM. - Prevents, does not reverse, formation of antibodies - Given prenatally with any invasive procedure at 28 weeks and after delivery - *Administer RhoGAM.* - Rho(D) immune globulin - IM - Given within 72 hr after delivery - **Thromboembolic Disorder** - **Contributing Factors** - Venous stasis and hypercoagulation - Immobility - Pelvic pressure during labor/delivery - History of thrombosis, varicosities, heart disease - **Manifestations** - Pain, heat, redness, swelling in lower leg or extremity - **Nursing Interventions**