Exam #3 Study Guide PDF

Exam #3 Study Guide Postpartum Postpartum Infection Postpartum Infections (1 of 3) ○ Also called puerperal (means postpartum) infection ○ Any clinical infection of the genital tract that occurs within 28 days after miscarriage, induced abortion, or birth ○ D...

Exam #3 Study Guide Postpartum Postpartum Infection Postpartum Infections (1 of 3) ○ Also called puerperal (means postpartum) infection ○ Any clinical infection of the genital tract that occurs within 28 days after miscarriage, induced abortion, or birth ○ Defined as presence of a fever of 38° C (100.4° F) in the first 10 postpartum days (not including the first 24 hours after birth) increased heart rate, fatigue, blood pressure- increased Endometritis (endomyometritis) ○ Infection of the lining of the uterus ○ Most common postpartum infection ○ Fundal tenderness, febrile ○ Prolonged rupture or membranes, manual introduction of bacteria Management: IV broad-spectrum antibiotic therapy ○ Gentamicin & Clindamycin ○ Treat for 24 hours afebrile ○ Don’t usually culture, just treat ○ Other reasons ruled out Wound infections ○ Often develop after mothers are discharged home ○ Rates of wound infection after cesarean birth are 3% to 5% ○ Cellulitis/Abscess of wound, laceration Urinary Tract Infections (UTIs) ○ Dysuria, burning, frequency, suprapubic pain. ○ Get UA ○ Foley, straight cath ○ Occur in 2% to 4% of postpartum women Other reasons for fever/ infection symptoms ○ Pneumonia, flu or other virus, DVT/PE, mastitis - infection of the milk ducts and this occurs in mom’s who just gave birth and apply hot compresses Mastitis can be treated with dicloxacillin Mastitis will be febrile, flu-like symptoms, true infection Misoprostol can cause a transient fever, not too high and no other symptoms. KEY POINTS* Postpartum hemorrhage is a major cause of obstetric morbidity and mortality throughout the world and is the leading reason for obstetric intensive care unit admissions. Hemorrhagic (hypovolemic) shock is an emergency situation in which the perfusion of body organs can become severely compromised and death can ensue. The potential side effects of therapeutic interventions can further compromise the woman with a hemorrhagic disorder. Clotting disorders are associated with many obstetric complications. Postpartum infection is a major cause of maternal morbidity and mortality throughout  the world. Postpartum UTIs are common because of trauma experienced during labor. Prevention is the most effective and least expensive treatment of postpartum infection. Postpartum bleeding and hemorrhage Hemorrhagic (Hypovolemic) Shock ○ Results from hemorrhage Emergency situation in which perfusion of organs may become severely compromised, death may occur ○ Interprofessional Care Management Standardized management protocols and Interprofessional teamwork are key Restoring circulating blood volume and eliminating the cause of the hemorrhage Fluid or blood replacement therapy Restore oxygen delivery to the tissues and to maintain cardiac output Management Uterine massage! Get help, call code hemorrhage Hemorrhage cart, Standing orders Large bore IV (18 gage sometimes 20), isotonic fluids Empty bladder so that it does not get in the way of the uterus Uterotonics ○ Pitocin ○ Hemabate- explosive diarrhea can be really uncomfortable , methergine, Cytotec CBC, Type/Screen, Blood products Physical pressure ○ Tamponade/packing with gauze, Pressure devices/ balloons (foley, Bakri balloon), fix underlying cause of bleeding, sweep to remove placental products, provider can do bimanual massage of the uterus Surgery ○ Uterine artery embolization, Surgically remove retained products, B-Lynch suture, repair lacerations or rupture, hysterectomy Postpartum Hemorrhage: Interprofessional Care Management Institutions must develop standardized management protocols and regularly conduct emergency drills  California Maternal Quality Care Collaborative: best practice approach Safety bundle for obstetric hemorrhage recommended: ○ Readiness; Recognition and Prevention; Response; Reporting and Systems Learning ○ file:///C:/Users/12012/Downloads/HemorrhageVisioFlowchart_v1.4.pdf Assessment ○ Early recognition and treatment of PPH are critical Medical Management ○ firm massage of the uterine fundus; empty bladder, continuous IV infusion of 10 to 40 units of oxytocin added; uterotonic medications Surgical Management Nursing Interventions PPH Causes: (4 T’s) Tone, Trauma, Tissue, Thrombin 1. Tone Subinvolution of the uterus: Delayed return of enlarged uterus to nonpregnant size and function  Caused by retained placental fragments and pelvic infection  S/S: Prolonged lochial discharge, irregular/excessive bleeding, hemorrhage in some cases, boggy uterus upon pelvic exam Inversion of the uterus: Potentially life-threatening but rare complication. The placenta remains attached to the uterus, and upon exiting will pull the uterus inside-out. The placenta should never be pulled forcefully out Management of PPH  Firm massage to uterus/fundus  Call a code hemorrhage/get help, hemorrhage cart, follow standing orders for PPH  IV access with large bore IV, administer isotonic fluids  Empty bladder to reduce distention  Administer uterotonics – Pitocin, hemabate, methergine, or Cytotec  Labs: CBC, Type/Screen, Blood products  Physical pressure: Tamponade/pack with gauze, insert a pressure device (jaeda, foley, bakri balloon), fix underlying cause of bleeding, sweep to remove placental products, HCP can do bimanual massage of uterus  Surgery: Uterine artery embolization, surgically remove retained products, b-lynch suture, repair lacerations or rupture, hysterectomy Appropriate postpartum care Strict adherence by all health care personnel to aspetic techniques during childbirth and the postpartum period is extremely important and the least expensive measure to prevent infection Newborn Nutrition/ Breastfeeding: Mastitis Definition & Symptoms: ○ Infectious breast process with flu-like symptoms: fever, chills, malaise, aches, headache, nausea, vomiting. ○ Localized breast pain, tenderness, hot/red area. ○ Commonly in the upper outer quadrant, usually 2-4 weeks postpartum. Predisposing Factors: ○ Inadequate breast emptying (engorgement, plugged ducts, fewer feedings, abrupt weaning, underwire bras). ○ Sore, cracked nipples (entry for bacteria: Staphylococcus, Streptococcus, E. coli). ○ Stress, fatigue, illness, poor nutrition. Prevention & Education: ○ Teach signs of mastitis before discharge. ○ Promptly contact healthcare provider if symptoms arise. Treatment: ○ Bed rest, antibiotics (dicloxacillin, cephalexin, clindamycin). ○ Pain/swelling relief (anti-inflammatory meds, cold compresses). ○ Continue breastfeeding, hand expression, or pumping. ○ Ensure adequate fluid intake and balanced diet.  Complications: ○ Breast abscess, chronic mastitis, fungal infections. ○ Preventable with early treatment. Breastfeeding & Illness: ○ Generally safe, even with maternal illness. ○ COVID-19: not transferred through breast milk. ○ Infected mothers should wear a mask, practice hand hygiene, and ideally have another caregiver for non-breastfeeding tasks. Contraindication to breastfeeding Breastfeeding contraindicated in a few circumstances ○ Newborns with galactosemia ○ Mothers who are positive for human T cell lymphotropic virus types I or II ○ Mothers with untreated brucellosis ○ Mothers with active tuberculosis ○ Mothers with active herpes simplex lesions on the breasts. ○ Mothers with HIV infection Considered a contraindication in the United States In developing countries wher e HIV is prevalent, the benefits of breastfeeding for infants outweigh the risk of contracting HIV from infected mothers Breastfeeding positions - Factors that MAY contribute to pain associated with breastfeeding: improper feeding position, fair skin, flat or retracted nipples. Breastfeeding positions. A, Football or clutch (under the arm) hold. B, Across the lap (modified cradle). C, Cradling. D, Side-lying. (A and B, Courtesy of Allison and Matthew Wyatt, Eagle, CO; C and D, Courtesy of Marjorie Pyle, RNC, Lifecircle, Costa Mesa, CA.) Engorgement - Physiological change: Engorgement is caused by the temporary congestion of veins and lymphatic vessels. - Appropriate intervention for treating engorgement o Applying ice packs o Cabbage leaves *Engorgement occurs around 3 days after birth and with appropriate treatment resolves within 24 hours. AAP Recommendations for breastfeeding - Breastfeeding infant first needs to be seen for a follow-up examination 48 to 72 hours after discharge. Scientific evidence is clear that human milk provides the best nutrition for infants Human milk is the gold standard for infant nutrition AAP recommends exclusive breastfeeding of human milk for the first 6 months and continued breastfeeding for at least 12 months The AAP recommends introducing solid foods after 6 months of age Storage of breastfeeding Neonate: Newborn feeding  U.S. breastfeeding rates have rise steadily past 10 years o Influenced by personal/ sociocultural factors Jaundice Jaunice in newborns differs from adults Newborns produce bilirubin 2-2.5 times that of an adult RBCs have a shorter lifespan Bili metabolism is initiated in the reticuloendothelial system, primarily liver and spleen. Bili binds tightly to albumin, its carrier protein. Enters the liver for conjugation and excretion Acute bilirubin encephalopathy or kernicterus Fetal loss communication Neonatal withdrawal Substance abuse ○ Tobacco Low birth weight is the most widely recognized effect of maternal tobacco use Other adverse perinatal outcomes ○ Alcohol There is no quantity, amount, frequency, or timing of alcohol intake during pregnancy that is considered safe Fetal alcohol spectrum disorders (FASDs) Fetal alcohol syndrome (FAS) Partial fetal alcohol syndrome  Alcohol-related neurodevelopmental disorder Alcohol-related birth defects Neurobehavioral disorder associated with Prenatal alcohol exposure (PAE) ○ Opioids Most popular opioids are morphine, heroin, methadone, meperdine, oxycodone, codeine, and fentanyl; readily crosses placenta Significant increase in the use and misuse of opioids in the U.S. Neonatal abstinence syndrome (NAS) describes the clinical signs that can be associated with withdrawal from opioids Breastfeeding recommendations ○ Marijuana Currently a lack of definitive evidence about the effects ○ Cocaine Recognized cause of placental abruption Infants have high risk of IUGR, low birth weight, and preterm birth; associated with longer-term effects ○ Amphetamines Limited data, although higher incidence of placental abruption, preterm birth, and SGA infants ○ Benzodiazepines and Barbiturates Signs of withdrawal from these substances are not seen until 7 to 21 days of age ○ Selective Serotonin Reuptake Inhibitors (SSRIs) Mainstay of treatment for depression and anxiety and are often prescribed during pregnancy Maternal use of SSRIs late in the pregnancy has been associated with preterm birth, low birthweight, and NICU admission Paroxetine be avoided during pregnancy as this SSRI has been shown to increase the risk of cardiovascular defects, specifically ventricular septal defects Care Management ○ The maternal history is the key to identification of newborns who are at risk ○ Thorough newborn assessment ○ Urine or meconium screening Nursing Considerations ○ Planning for care: challenges ○ Education and Social support ○ Care for infant experiencing withdrawal Supportive Care Medications Issue of Breastfeeding Support for mother Neonatal heat loss - 4: conduction, conversion, evaporation, and radiation - Apgar score The Apgar score is a quick evaluation of a newborn baby's health immediately after birth. It measures the baby's appearance, pulse, grimace, activity, and respiration. A score of 7 or above is considered good Infant of a diabetic mother  Hyperinsulinemia: increased amounts of glucose cross placenta and stimulate fetal pancreas to release insulin  Increased congenital anomalies (babies of pregestational DM moms) o Macrosomia (big shoulders leads to dystocia) o Birth trauma and perinatal hypoxia o Respiratory distress syndrome (mom’s high BG affects baby lung development) o Hypoglycemia (jitters, apnea, tachypnea, cyanosis) o Hypocalcemia and hypomagnesemia (onsets 2-3 days after birth) o Cardiomyopathy o Hyperbilirubinemia and polycythemia  Increased number RBCs increases bilirubin load neonate must clear... increases likelihood of hyperbilirubinemia Assessment of the neonate’s head Caput succedaneum and cephalhematoma are commonly seen in neonates. Caput succedaneum is subcutaneous edema over the presenting part, often as the result of pressure on the fetal head pushing through a dilated cervix (see Fig. 23.15A). Cephalhematoma is a collection of subperiosteal blood; because it is under the periosteum, it does not cross the suture lines (see Fig. 23.15B). A more serious injury is a subgaleal hemorrhage, which is bleeding into the subgaleal compartment (see Fig. 23.15C). This area is considered a potential space because it can hold up to 240 mL of blood—the blood volume of a 3-kg newborn. Characteristics of the preterm neonate Neonatal hypoglycemia Hypoglycemia ○ Signs include jitteriness, apnea, tachypnea, decreased activity and cyanosis Skin-to-skin care Neonatal infection  Susceptible to infection bc immature immune system  Sepsis o Most significant cause of neonatal morbidity and mortality: Systemic Inflammatory Response Syndrome (SIRS) o Early- and late-onset sepsis  Viral infections: varicella, rubella (congenital), Hep B, HIV, Herpes Simplex, influenza  Bacterial: GBS, E.coli, chlamydia, gonorrhea, syphilis (black spots on baby’s feet)  Protozoal infection: toxoplasmosis  Fungal: candidiasis Neonatal immunity Immunity ○ shortage of stored maternal immunoglobulins (IgG) ○ impaired ability to make antibodies ○ compromised integumentary system Respiratory distress in the neonate True apnea is a pause of breathing for 20 seconds or more. Hypotonia Baby comes into the NICU, we are thinking infection and want to RULE OUT infection. CBC, ABx  Signs of respiratory distress: ○ https://youtu.be/NBA9iigiDgk Respiratory Distress Syndrome (RDS) ○ Caused by a lack of pulmonary surfactant, which leads to progressive atelectasis, loss of functional residual capacity, and ventilation-perfusion imbalance Maternal hyperglycemia can affect fetal lung maturity five times that of pregnant women who do not have diabetes Cardiac murmur in the neonate  Sinus dysrhythmia is normal  Murmurs can be normal BUT must have follow assessment to confirm Neonatal skin findings Newborn vital signs  HR: 100-160  RR: 30-60 bpm