MATERNAL NEWBORN 275 Proctored-Final Study Guide Newly Updated 2022

OB PROCTORED/FINAL STUDY GUIDE 1. PREMONITORY SIGNS OF LABOR a. Backache b. Weight loss (1-3 lbs.) c. Lightening i. Fetal head descends into pelvis ii. Around 14 days before labor iii. Feeling that fetus has “dropped” d. Easier breathing e. Increased bladder pressure i. Urinary frequency ii. More pronounced w/ primigravida f. Contractions i. Starts w/ Braxton Hicks (irregular) ii. Progresses in strength & regularity g. Bloody show i. Brownish, blood tinged mucus plug 1. Onset of cervical dilation & effacement h. Energy burst i. Gastrointestinal changes j. Rupture of membranes i. Can initiate labor or occur anytime during labor 1. FIVE FACTORS (“5 P’s”) a. Affect & define labor & birth process i. Passenger 1. Fetus & placenta 1. Fetal presentation i. Part of the fetus that is entering pelvic inlet first 1. Occiput – back of the head 2. Mentum – chin 3. Scapula – shoulder 4. Breech – sacrum or feet 2. Lie i. Relationship of maternal longitudinal axis (spine) to fetal longitudinal axis (spine) 1. Transverse: Fetal long axis is horizontal 2. Forms right angle to maternal axis 3. Cannot have vaginal birth 4. Shoulder is presenting part 5. Cesarean required if fetus doesn’t rotate 3. Attitude i. Relationship of fetal body parts to one another 1. Fetal flexion a. Chin flexed to chest b. Extremities flexed into torso 2. Fetal extension a. Chin extended away from chest b. Extremities extended 4. Fetopelvic/Fetal position i. Relationship of presenting part of fetus in reference to its position as it relates to one of the 4 maternal pelvic quadrants 1. Right (R) or left (L) a. References either side of maternal pelvis 2. Occiput (O), sacrum (S), mentum (M) or scapula (Sc) 5. Station a. 2nd letter references presenting part of fetus 3. Anterior (A), posterior (P) or transverse (T) a. 3rd letter references part of maternal pelvis ii. Passageway 1. Birth canal i. Measurement of fetal descent in centimeters 1. Station 0 being level of imaginary line at level of ischial spines 2. Minus stations superior to ischial spines 3. Plus stations inferior to ischial spines iii. Powers 1. Bony pelvis i. Must be adequate to allow fetus to pass thru 2. Cervix i. Must dilate & efface in response to contractions & fetal decent 3. Pelvic floor 4. Vagina 5. Introitus (vaginal opening) 1. Uterine contractions cause effacement during 1st stage of labor 2. Dilation of cervix occurs once labor has begun & fetus is descending 3. Involuntary urge to push 4. Voluntary bearing down in 2nd stage of labor 5. Helps in expulsion of fetus iv. Position 1. Client should engage in frequent position changes during labor 1. Increase comfort 2. Relieve fatigue 3. Promotes circulation 2. Position during 2nd stage is determined by: 1. Maternal reference 2. Provider preference 3. Condition of mother & fetus v. Psychological response 1. Maternal stress 2. Tension 3. Anxiety 1. Can produce physiological changes that impair labor progress 4. MECHANISM OF LABOR a. Engagement i. Presenting part passes pelvic inlet at level of ischial spines ii. Usually biparietal (largest) diameter of fetal head iii. Referred to as station 0 b. Descent i. Progress of presenting part through pelvis ii. Preferably occiput iii. Measured by station during vaginal exam as either: 1. Negative (-) station: measured in centimeters if superior to station 0 & not yet engaged 2. Positive (+) station: measured in centimeters if inferior to station 0 c. Flexion i. When fetal head meets resistance of cervix, pelvic wall or pelvic floor ii. Head flexes, bringing chin close to chest iii. Presenting smaller diameter to pass thru pelvis d. Internal rotation i. Fetal occiput ideally rotates to lateral anterior position as it progresses from ischial spines to lower pelvis ii. Corkscrew motion to pass thru pelvis e. Extension i. Fetal occiput passes under symphysis pubis ii. Head is deflected anteriorly iii. Born by extension of chin away from fetal chest f. External Rotation “Restitution” i. After head is born, it rotates to position it occupied as it entered pelvic inlet in alignment w/ fetal body ii. Completes a ¼ turn to face transverse as anterior shoulder passes under symphysis g. Birth by Expulsion i. After birth of head & shoulders, trunk of neonate is born by flexing towards symphysis pubis 5. STAGES OF LABOR a. First stage (12.5 hrs): onset of labor to complete dilation i. Latent phase (4-6 hrs) 1. Onset of labor 2. Contractions 1. Irregular 2. Mild to moderate 3. Frequency: 5-30 min 4. Duration: 30-45 sec 3. Dilation: 0-3 cm ii. Active phase (2-3 hrs) 1. Contractions 1. More regular 2. Moderate to strong 3. Frequency: 3-5 min 4. Duration: 40-70 sec 2. Dilation: 4-7 cm iii. Transition (20-40 min) 1. Contractions 1. Strong to very strong 2. Frequency: 2-3 min 3. Duration: 45-90 sec 2. Dilation: 8-10 cm 1. Complete dilation (10 cm) iv. Pain 1. Internal visceral pain 2. Back and leg pain 1. Caused by: i. Dilation ii. Effacement iii. Stretching of the cervix iv. Distention of the lower segment of the uterus v. Contractions of the uterus with resultant uterine ischemia b. Second stage (5 min – 2 hrs) i. Full dilation ii. Progresses to intense contractions every 1-2 min iii. Pain 1. Somatic 2. Occurs w/ fetal descent & expulsion 3. Caused by: 1. Pressure & distention of vagina & perineum 2. “Burning, splitting, tearing” 3. Pressure & pulling on pelvic structures i. Ligaments ii. Fallopian tubes iii. Ovaries iv. Bladder v. Peritoneum 4. Lacerations of soft tissues i. Cervix ii. Vagina iii. Perineum c. Third stage (5-30 min) i. Delivery of neonate ii. Pain 1. Expulsion of the placenta 2. Similar to the pain experienced during the first stage 3. Caused by: 1. Uterine contractions 2. Pressure and pulling of pelvic structures d. Fourth stage (1-4 hrs) i. Delivery of placenta ii. Maternal stabilization of vital signs iii. Pain 1. Caused by: 1. Distention and stretching of the vagina and perineum 2. Incurred during the second stage with a splitting, burning, and tearing sensation 3. PAIN MEDICATIONS a. Opioids i. Acts in CNS to decrease perception of pain without loss of consciousness 1. Meperidine Hydrochloride (Demerol) 2. Fentanyl (Sublimaze) 3. Butorphanol (Stadol) 1. Pain relief without significant respiratory depression in mother or fetus 4. Nalbuphine (Nubain) 1. Pain relief without significant respiratory depression in mother or fetus ii. IV or IM (IV preferred due to quicker action) iii. Adverse reactions 1. Crosses placental barrier 1. If given to mother too close to time of delivery, 2. Respiratory depression in neonate 3. Reduces gastric emptying 4. Increases the risk for nausea and emesis 5. Increases the risk for aspiration of food or fluids in the stomach 6. Sedation 7. Tachycardia 8. Hypotension 9. Decreased FHR variability 10. Allergic reaction b. Sedatives (barbiturates) i. Not typically used during birth 1. Do not administer if birth is anticipated within 12-24 hours ii. Can be used during early/latent phase to relieve anxiety & induce sleep 1. Secobarbital (Seconal) 2. Pentobarbital (Nembutal) 3. Phenobarbital (Luminal) iii. Adverse effects: 1. Neonate respirator depression 1. Secondary to medication crossing placenta 2. Unsteady ambulation c. Epidural/Spinal Regional Analgesia i. Consists of local anesthetic & an analgesic ii. Administered as a motor block into epidural or intrathecal space 1. 4th or 5th vertebrae 2. Short acting opioids 1. Fentanyl (Sublimaze) 2. Sufentanil (Sufenta) 3. Morphine (Duramorph) 3. Local anesthetic 1. Bupivacaine (Marcaine) iii. Administered when client is in active labor & dilated at least 4 cm iv. Regional analgesia v. Rapid pain relief 1. Eliminates all sensation from umbilicus to thighs 2. Relieves discomfort of: 1. Uterine contractions 2. Fetal descent 3. Pressure & stretching of perineum vi. Allows client to sense contractions & ability to bear down vii. Adverse effects: 1. Decreased gastric emptying 1. Results in nausea and vomiting 2. Inhibition of bowel and bladder elimination sensations 3. Bradycardia or tachycardia 4. Hypotension 5. Respiratory depression 6. Allergic reaction and pruritus 7. Elevated temperature d. Pudendal block i. Local anesthetic to perineum, vulva & rectal area 1. Lidocaine (Xylocaine) 2. Bupivacaine (Marcaine) ii. Administered transvaginally into the space in front of the pudendal nerve iii. No maternal or fetal systemic effect iv. Used during delivery, episiotomy, and episiotomy repair. v. Provides analgesia prior to spontaneous expulsion of the fetus, forceps-assisted or vacuum-assisted birth vi. Administered during 2nd stage of labor 1. 10 to 20 min before delivery providing. vii. Adverse effects: 1. Broad ligament hematoma 2. Compromise of maternal bearing down reflex 4. LEOPOLD MANEUVER a. Performing external palpations of maternal uterus through the abdominal wall to determine the following: i. Number of fetuses ii. Presenting part, fetal lie, and fetal attitude iii. Degree of descent of the presenting part into the pelvis iv. Expected location of the point of maximal impulse (PMI) 5. FETAL ASSESSMENT DURING LABOR a. PMI i. Optimal location where fetal heart tones are auscultated the loudest on the woman’s abdomen. ii. Tones are best heard directly over the fetal back 1. In vertex presentation: 1. PMI is either in the right- or left-lower quadrant or below the maternal umbilicus. 2. In breech presentation: 1. PMI is either in the right- or left-upper quadrant above the maternal umbilicus. 6. FETAL HEART RATE INTERPRETATIONS a. Normal fetal heart rate baseline at term i. 110 to 160/min excluding accelerations, decelerations, and periods of marked variability within a 10 min window. ii. At least 2 min of baseline segments in a 10 min window should be present. iii. A single number should be documented instead of a baseline range. b. Fetal heart rate baseline variability: Fluctuations in the FHR baseline that are irregular in frequency and amplitude. c. Classification of variability: i. Absent or undetectable variability (considered nonreassuring) ii. Minimal variability (greater than undetectable but less than 5/min) iii. Moderate variability (6 to 25/min) iv. Marked variability (greater than 25/min) d. Three Tier System i. Category I 1. All of the following are included in the fetal heart rate tracing: 1. Baseline fetal heart rate of 110 to 160/min 2. Baseline fetal heart rate variability: moderate 3. Accelerations: present or absent 4. Early decelerations: present or absent 5. Variable or late decelerations: absent ii. Category II: 1. Category II tracings include all fetal heart rate tracings not categorized as Category I or Category III 1. Baseline rate i. Tachycardia ii. Bradycardia not accompanied by absent baseline variability 2. Baseline FHR variability i. Minimal baseline variability ii. Absent baseline variability not accompanied by recurrent decelerations iii. Marked baseline variability 3. Episodic or periodic decelerations i. Prolonged fetal heart rate deceleration greater than 2 min but less than 10 min ii. Recurrent late decelerations with moderate baseline variability iii. Recurrent variable decelerations with minimal or moderate baseline variability iv. Variable decelerations with additional characteristics, including “overshoots,” “shoulders,” or slow return to baseline fetal heart rate 4. Accelerations i. Absence of induced accelerations after fetal stimulation iii. Category III: 1. Category III fetal heart rate tracings include either: 1. Sinusoidal pattern 2. Absent baseline fetal heart rate variability and any of the following: i. Recurrent variable decelerations ii. Recurrent late decelerations iii. Bradycardia 3. Each uterine contraction is comprised of the following: i. Increment 1. The beginning of the contraction as intensity is increasing 2. Acme a. The peak intensity of the contraction 3. Decrement a. The decline of the contraction intensity as the contraction is ending 4. Nonreassuring FHR patterns are associated with fetal hypoxia and include the following: i. Fetal bradycardia ii. Fetal tachycardia iii. Absence of FHR variability iv. Late decelerations v. Variable decelerations 7. FETAL MONITORING a. Fetal Scalp Electrode (FSE) i. Continuous internal fetal monitoring with a scalp electrode ii. Attachment of a small spiral electrode to the presenting part of the fetus iii. The electrode wires are then attached to a leg plate that is placed on the client’s thigh and then attached to the fetal monitor. b. Intra Uterine Pressure Catheter (IUPC) i. Solid or fluid-filled transducer placed inside the client’s uterine cavity to monitor the frequency, duration, and intensity of contractions. ii. Average pressure is usually 50 to 85 mm Hg. 8. NURSING CARE DURING LABOR a. Vaginal Exam i. Avoid vaginal examinations in the presence of vaginal bleeding 1. Until placenta previa or placenta abruptio is ruled out. ii. If necessary, vaginal examinations should be done by the provider. b. Cervical dilation is the single most important indicator of the progress of labor. i. The progress of labor is affected by 1. fetal lie 2. presentation 3. attitude 4. fetal size in relationship to the mother’s pelvis c. The frequency, duration, and strength (intensity) of the uterine contractions cause fetal descent and cervical dilation. 9. NURSING CARE DURING 1ST STAGE OF LABOR a. Leopold maneuvers performed b. Perform a vaginal examination c. Assessments related to possible rupture of membranes d. Perform bladder palpation on a regular basis to prevent bladder distention i. Can impede fetal descent through the birth canal and cause trauma to the bladder e. Blood pressure, pulse, and respiration measurements f. Temperature assessment every 4 hr (every 1 to 2 hr if membranes have ruptured) g. Contraction monitoring h. FHR monitoring (normal range 110 to 160/min) 10. NURSING CARE DURING 2ND STAGE OF LABOR a. Begins with complete dilation and effacement i. Blood pressure, pulse, and respiration measurements every 5 to 30 min ii. Uterine contractions iii. Pushing efforts by client iv. Increase in bloody show v. FHR every 15 min and immediately following birth 11. NURSING ASSESSMENT DURING 3RD STAGE OF LABOR a. Blood pressure, pulse, and respiration measurements every 15 min b. Signs of placental separation from the uterus as indicated by: i. Fundus firmly contracting ii. Swift gush of dark blood from introitus iii. Umbilical cord appears to lengthen as placenta descends iv. Vaginal fullness on exam v. Assignment of 1 and 5 min Apgar scores to the neonate 12. NURSING ASSESSMENT DURING 4TH STAGE OF LABOR a. Maternal vital signs b. Fundus c. Lochia d. Urinary output e. Baby-friendly activities of the family f. Breastfeeding stimulates the release of endogenous oxytocin from the pituitary gland. g. Medication: i. Pitocin (exogenous oxytocin) 1. Improves quality of uterine contractions. 2. A firm and contracted uterus prevents excessive bleeding and hemorrhage. h. Afterpains: Uncomfortable uterine cramping. 13. LABOR LACERATIONS a. 1st degree i. Laceration extends through the skin of the perineum ii. Does not involve the muscles b. 2nd degree i. Laceration extends through the skin and muscles into the perineum. c. 3rd degree i. Laceration extends through the skin, muscles, perineum, and anal sphincter muscle. d. 4th degree i. Laceration extends through skin, muscles, anal sphincter, and the anterior rectal wall. ii. Insert nothing in rectum with 4th degree laceration. 14. THERAPEUTIC PROCEDURES DURING LABOR a. External cephalic version (ECV) i. Attempt to manipulate the abdominal wall to direct a malpositioned fetus into a normal vertex presentation ii. After 37 weeks of gestation iii. High risk of prolapse of umbilical cord iv. Contraindications: 1. Uterine anomalies 2. Previous cesarean birth 3. Cephalopelvic disproportion 4. Placenta previa 5. Multifetal gestation 6. Oligohydramnios 15. BISHOPS SCORE a. Used to determine maternal readiness for labor by evaluating whether the cervix is favorable by rating the following: i. Cervical dilation ii. Cervical effacement iii. Cervical consistency (firm, medium, or soft) iv. Cervical position (posterior, midposition, or anterior) v. Station of presenting part b. The five factors are assigned a numerical value of 0 to 3, and the total score is calculated. c. Score for a client at 39 weeks of gestation i. Should be greater than 8 for a multiparous client ii. Should be greater than 10 for a nulliparous client 16. CERVICAL RIPENING a. Increases cervical readiness for labor through promotion of cervical softening, dilation, and effacement. b. Two methods: i. Mechanical/Physical methods 1. Balloon catheter 2. Membrane stripping & amniotomy 3. Hygroscopic dilators & sponges 1. Laminaria 2. Lamicell ii. Chemical methods 1. Based on prostaglandins 2. Either orally or vaginally 1. Misoprostol (Cytotec) 2. Prostaglandin E1 3. Dinoprostone (Cervidil, Prostaglandin E2) c. Complications: i. Hyperstimulation d. Nursing actions i. Administer subcutaneous injection of terbutaline (Brethine). 17. INDUCTION OF LABOR a. Deliberate initiation of uterine contractions to stimulate labor before spontaneous onset to bring about the birth either by chemical or mechanical means. b. Methods: i. Chemical 1. IV oxytocin (Pitocin) ii. Mechanical 1. Nipple stimulation to trigger the release of endogenous oxytocin c. Indications: i. Any condition in which augmentation or induction of labor is indicated. d. Elective induction for nonmedical indications must meet criteria i. At least 39 weeks of gestation ii. Bishop score: 1. Multiparous client: Greater than 8 2. Nulliparous client: greater than 10 iii. Elective inductions that do not meet recommended criteria can result in increased risk for: 1. Infection 2. Premature delivery 3. Longer labor 4. Need for cesarean birth. 18. AUGMENTATION OF LABOR a. Stimulation of hypotonic contractions once labor has spontaneously begun, but progress is inadequate. 19. AMNIOTOMY a. Artificial rupture of the amniotic membranes (AROM) by the provider using an Amnihook or other sharp instrument. b. Labor typically begins within 12 hr after the membranes rupture. c. Client is at an increased risk for cord prolapse or infection d. Indication: i. Labor progression is too slow ii. Cord compression 20. AMNIOINFUSION a. Instillation of 0.9% sodium chloride or lactated Ringer’s solution into amniotic cavity through a transcervical catheter b. Introduced into the uterus to supplement the amount of amniotic fluid c. Instillation will reduce severity of variable decelerations caused by cord compression d. Indication: i. Oligohydramnios (scant amount or absence of amniotic fluid) 1. Caused by any of the following: 1. Uteroplacental insufficiency 2. Premature rupture of membranes 3. Post maturity of the fetus 4. Fetal cord compression secondary to: i. Post maturity of fetus (macrosomic, large body) 1. Places the fetus at risk for variable deceleration from cord compression 21. EPISIOTOMY a. An incision made into the perineum to enlarge the vaginal opening to facilitate delivery and minimize soft tissue damage. b. Site and direction of the incision designates the type of episiotomy: i. Midline ii. Mediolateral c. Indications: i. Shortens the second stage of labor ii. Facilitates forceps-assisted or vacuum-assisted delivery iii. Prevent cerebral hemorrhage in a fragile preterm fetus iv. Facilitate birth of a macrosomic (large) infant 22. VACUUM ASSISTED DELIVERY a. Use of cuplike suction device that is attached to the fetal head. b. Traction is applied during contractions to assist in the descent and birth of the head c. Vacuum cup is released and removed preceding delivery of the fetal body d. Indications: i. Vertex presentation ii. Absence of cephalopelvic disproportion iii. Ruptured membranes e. Possible results i. Scalp lacerations ii. Subdural hematoma of the neonate iii. Cephalohematoma iv. Maternal lacerations to the cervix, vagina, or perineum 23. FORCEPS ASSISTED DELIVERY a. Using an instrument with two curved spoon-like blades to assist in the delivery of the fetal head. b. Traction is applied during contractions. c. Indications i. Fetal distress during labor ii. Abnormal presentation or a breech position requiring delivery of the head iii. Arrest of rotation iv. Maternal exhaustion v. Ineffective pushing efforts d. Complications: i. Lacerations of the cervix ii. Lacerations of the vagina and perineum iii. Injury to the bladder iv. Facial nerve palsy of the neonate v. Facial bruising on the neonate 24. CESAREAN BIRTH a. Delivery of fetus through a transabdominal incision of the uterus to preserve the life or health of the client and fetus when there is evidence of complications. b. Incisions are made horizontally into the lower segment of the uterus c. Indications: i. Malpresentation ii. Particularly breech presentation iii. Cephalopelvic disproportion iv. Fetal distress v. Placental abnormalities 1. Placenta previa 2. Abruptio placenta) vi. High-risk pregnancy 1. Positive HIV status 2. Hypertensive disorders 1. Preeclampsia 2. Eclampsia 3. Diabetes mellitus 4. Active genital herpes lesions 5. Previous cesarean birth 6. Dystocia 7. Multiple gestations 8. Umbilical cord prolapse d. Complications i. Maternal: 1. Aspiration 2. Amniotic fluid pulmonary embolism 3. Wound infection 4. Wound dehiscence 5. Severe abdominal pain 6. Thrombophlebitis 7. Hemorrhage 8. Urinary tract infection 9. Injuries to the bladder or bowel 10. Anesthesia associated complications ii. Fetal: 1. Premature birth of fetus if gestational age is inaccurate 2. Fetal injuries during surgery 25. VAGINAL DELIVERY AFTER C-SECTION (VBAC) a. Client delivers vaginally after having had a previous cesarean birth b. Indications: i. No other uterine scars or history of previous rupture ii. 1 or 2 previous low transverse cesarean births iii. Clinically adequate pelvis iv. Previous documented low-segment transverse incision v. No current contraindications such as: 1. Large for gestational age newborn 2. Malpresentation 3. Cephalopelvic disproportion 4. Previous classical vertical uterine incision 26. COMPLICATIONS OF LABOR a. Considered emergent and require immediate intervention in order to improve maternal fetal outcomes. b. Prolapsed umbilical cord i. Occurs when umbilical cord is displaced, preceding the presenting part of the fetus, or protruding through the cervix. ii. Results in cord compression and compromised fetal circulation. iii. Risk factors: 1. Rupture of amniotic membranes 2. Abnormal fetal presentation: 3. Transverse lie 1. Presenting part is not engaged 2. Leaves room for the cord to descend 4. Small-for-gestational-age fetus 5. Unusually long umbilical cord 6. Multifetal pregnancy 7. Cephalopelvic disproportion 1. Due to unusual space between maternal pelvis and presenting part, which allows for cord descent 8. Placenta previa 9. Intrauterine tumor 1. Prevents engagement of presenting part, 10. Polyhydramnios c. Complete cord prolapse i. Cord is visible at the vaginal opening d. Palpated cord prolapse i. Cannot be seen but felt as a pulsating structure when a vaginal exam is done e. Occult cord prolapse 1. Hidden and cannot be seen or felt 2. Suspected on basis of abnormal fetal heart rates f. Expected findings: 1. Client reports feeling of something coming through vagina. 2. Visualization or palpation of the umbilical cord protruding from the introitus 3. FHR monitoring shows variable or prolonged deceleration 4. Excessive fetal activity followed by cessation of movement 1. Suggestive of severe fetal hypoxia g. Nursing care: 1. Call for assistance immediately. 2. Notify the provider. 3. Use a 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. 4. Reposition the client in a knee-chest, Trendelenburg, or a side-lying position with a rolled towel under the client’s right or left hip to relieve pressure on the cord 5. Apply a warm, sterile, saline-soaked towel to the visible cord to prevent drying and to maintain blood flow. 6. Provide continuous electronic monitoring of FHR for variable decelerations, which indicate fetal asphyxia and hypoxia. 7. Administer oxygen at 8 to 10 L/min via a face mask to improve fetal oxygenation. 8. Initiate IV access, and administer IV fluid bolus. 9. Prepare for a cesarean birth 27. MECONIUM STAINED AMNIOTIC FLUID a. Meconium in the amniotic fluid during the antepartum period prior to the start of labor is typically not associated with an unfavorable fetal outcome. b. The fetus has had an episode of loss of sphincter control, allowing meconium to pass into amniotic fluid. c. Risk Factors: i. After 38 weeks of gestation 1. Due to fetal maturity of normal physiological functions ii. Umbilical cord compression 1. Results in fetal hypoxia that stimulates the vagal nerve in mature fetuses iii. Hypoxia stimulates the vagal nerve 1. Induces peristalsis of the fetal gastrointestinal tract and relaxation of the anal sphincter. d. Findings i. Amniotic fluid may vary in color 1. Black to greenish, yellow, red (bloody), or brown. 2. Consistency may be thin or heavy. ii. Criteria for evaluation of meconium stained fluid 1. Often present in breech presentation, and may not indicate fetal hypoxia 2. Present with no changes in FHR 3. Stained fluid accompanied by variable or late decelerations in FHR (ominous sign) e. Diagnostic Procedures 1. Electronic fetal monitoring f. Nursing care: 1. Document color and consistency of stained amniotic fluid. 2. Notify neonatal resuscitation team to be present at birth. 3. Gather equipment needed for neonatal resuscitation. 4. Follow designated suction protocol. 5. Assess neonate’s respiratory efforts, muscle tone, and heart rate. 6. Suction mouth and nose using bulb syringe if respiratory efforts strong, muscle tone good, and heart rate greater than 100/min. 7. Suction below the vocal cords using an endotracheal tube before spontaneous breaths occur if respirations are depressed, muscle tone decreased, and heart rate less than 100/min 28. FETAL DISTRESS a. The FHR is below 110/min or above 160/min. b. The FHR shows decreased or no variability. c. There is fetal hyperactivity or no fetal activity d. Risk Factors: i. Fetal anomalies ii. Uterine anomalies iii. Complications of labor and birth e. Nursing Care: i. Monitor vital signs and FHR. ii. Position the client in a left side-lying reclining position with legs elevated. iii. Administer 8 to 10 L/min of oxygen via a face mask. iv. Discontinue oxytocin (Pitocin) if being administered. v. Increase IV fluid rate to treat hypotension if indicated. vi. Prepare the client for an emergency cesarean birth vii. Nonreassuring FHR pattern with decreased or no variability f. Diagnostic procedures i. Monitor uterine contractions. ii. Monitor FHR. iii. Monitor findings of ultrasound and any other prescribed diagnostics 29. DYSTOCIA (DYSFUNCTIONAL LABOR) a. Difficult or abnormal labor related to the five powers of labor i. passenger, passageway, powers, position, and psychologic response) b. Atypical uterine contraction patterns prevent the normal process of labor and its progression. c. Contractions can be hypotonic or hypertonic i. Hypotonic 1. Weak 2. Inefficient 3. Completely absent ii. Hypertonic 1. Excessively frequent 2. Uncoordinated 3. Strong intensity 4. Inadequate uterine relaxation 5. Failure to efface and dilate the cervix d. Risk factors: i. Short stature ii. Overweight status iii. Age greater than 40 years iv. Uterine abnormalities v. Pelvic soft tissue obstructions or pelvic contracture vi. Cephalopelvic disproportion 1. Fetal head is larger than maternal pelvis vii. Fetal macrosomia viii. Fetal malpresentation or malposition ix. Multifetal pregnancy x. Hypertonic or hypotonic uterus xi. Maternal fatigue, fear, or dehydration xii. Inappropriate timing of anesthesia or analgesics e. Expected Findings: i. Lack of progress in dilatation, effacement, or fetal descent during labor 1. A hypotonic uterus is easily indentable, even at peak of contractions. 2. A hypertonic uterus cannot be indented, even between contractions. ii. Client is ineffective in pushing with no voluntary urge to bear down. 1. Persistent occiput posterior presentation is when the fetal occiput is directed toward the posterior maternal pelvis rather than the anterior pelvis. 2. Persistent occiput posterior position prolongs labor and the client reports greater back pain as the fetus presses against the maternal sacrum. f. Treatment: i. Oxytocin (Pitocin) 1. Used to augment labor and strengthen uterine contractions 30. ABNORMAL FETAL SIZE a. Macrosomia i. Large fetus ii. Weighs more than 4000 g (8.8 pounds) iii. May not fit through birth canal iv. Can contribute to hypotonic labor dysfunction v. May cause dysfunctional labor vi. Uterine over distention contributes to poor contraction quality vii. Abnormal presentation or position of one or more fetuses interferes with labor mechanisms 1. Often one fetus is delivered as cephalic and the second as breech, unless a version is done 31. SHOULDER DYSTOCIA a. After the delivery of the head, the anterior shoulder of the infant cannot pass below, or requires significant manipulation to pass below, the pubic symphysis b. Usually occurs when fetus is too large (GDM) c. Is an emergency d. Fetal chest cannot expand and the fetus needs to be able to breathe 32. PRECIPITOUS LABOR a. Labor that lasts 3 hr or less from the onset of contractions to the time of delivery. b. Risk Factors: i. Hypertonic uterine dysfunction 1. Nonproductive, uncoordinated, painful, uterine contractions during labor that are too frequent and too long in duration and do not allow for relaxation of the uterine muscle between contractions (uterine tetany) 2. Hypertonic contractions do not contribute to the progression of labor (cervical effacement, dilation, and fetal descent). 3. Hypertonic contractions can result in uteroplacental insufficiency leading to fetal hypoxia. ii. Oxytocin (Pitocin) stimulation 1. Administered to augment or induce labor by increasing intensity and duration of contractions 2. Oxytocin stimulation can lead to hypertonic uterine contractions. iii. Multiparous client 1. May move through the stages of labor more rapidly. c. Expected findings i. Fetal oxygenation may be compromised ii. Birth injury may occur from rapid passage through the birth canal 1. Intracranial hemorrhage 2. Nerve damage d. Nursing care i. Do not leave the client unattended. ii. Provide reassurance and emotional support to help the client remain calm. iii. Prepare for emergency delivery of the neonate. iv. Encourage the client to pant with an open mouth between contractions to control the urge to push v. Encourage the client to maintain a side-lying position to optimize uteroplacental perfusion and fetal oxygenation. vi. Prepare for rupturing of membranes upon crowning (fetal head visible at perineum) if not already ruptured. vii. Do not attempt to stop delivery viii. Control rapid delivery by applying light pressure to the perineal area and fetal head, gently pressing upward toward the vagina. 1. This eases the rapid expulsion of the fetus and prevents cerebral damage to the newborn and perineal lacerations to the client. ix. Deliver the fetus between contractions assuring the cord is not around the fetal neck. x. If the cord is around the fetal neck, attempt to gently slip it over the head. If not possible, clamp the cord with two clamps and cut between the clamps. e. Complications i. Maternal 1. Cervical, vaginal, and/or perineal lacerations 2. Resultant tissue trauma secondary to rapid birth 3. Uterine rupture 4. Amniotic fluid embolism 5. Postpartum hemorrhage ii. Fetal/neonate 1. Fetal hypoxia due to hypertonic contractions or umbilical cord around fetal neck 2. Fetal intracranial hemorrhage due to head trauma from rapid birth 33. UTERINE RUPTURE a. Complete rupture i. Involves the uterine wall, peritoneal cavity, and/or broad ligament. ii. Internal bleeding is present. b. Incomplete rupture i. Occurs with dehiscence at the site of a prior scar (cesarean birth, surgical intervention). ii. Internal bleeding may not be present. c. Risk Factors: i. Congenital uterine abnormality ii. Uterine trauma due to accident or surgery (previous multiple cesarean births) iii. Over distention of the uterus from a fetus who is large for gestational age iv. A multifetal gestation v. Polyhydramnios vi. Hyperstimulation of the uterus 1. Either spontaneous or from oxytocin (Pitocin) administration vii. External or internal fetal version done to correct malposition of the fetus viii. Forceps-assisted birth ix. Multigravida clients d. Expected Findings i. Suddenly onset of severe signs and symptoms such as: 1. Client reports sensation of “ripping,” “tearing,” or sharp pain, abdominal pain, and uterine tenderness. ii. Shock caused By bleeding into the abdomen iii. Pain in the chest, between the scapulae or with inspiration iv. Cessation of contractions v. Abnormal or absent fetal tones vi. Palpating of the fetus outside the uterus vii. Manifestations of hypovolemic shock 1. Tachypnea 2. Hypotension 3. Pallor 4. Cool, clammy skin viii. Nonreassuring FHR with signs of distress, bradycardia, variable and late decelerations, and absent or minimal variability ix. Change in uterine shape and fetal parts palpable x. Loss of fetal station e. Nursing Care i. Administer IV fluids. ii. Administer blood product transfusions if prescribed. iii. Prepare the client for an immediate cesarean birth, which may involve a laparotomy and/or hysterectomy. iv. Inform the client and her partner about the treatment. 34. ANAPHYLACTOID SYNDROME OF PREGNANCY (AMNIOTIC FLUID EMBOLISM) a. Occurs when there is a rupture in the amniotic sac or maternal uterine veins accompanied by high intrauterine pressure that causes infiltration of the amniotic fluid into the maternal circulation. b. The amniotic fluid then travels to and obstructs pulmonary vessels and causes respiratory distress and circulatory collapse. c. Meconium-stained amniotic fluid or fluid containing particulate matter can cause devastating maternal damage because it readily clogs the pulmonary veins completely d. Serious coagulation problems, such as disseminated intravascular coagulopathy (DIC), can occur. e. Risk factors: i. Multiparity and advanced maternal age ii. Tumultuous labor iii. Placenta previa iv. Abruptio placentae v. Preeclampsia vi. Oxytocin (Pitocin) administration vii. Fetal macrosomia viii. Hydramnios ix. Fetal demise x. Meconium-stained amniotic fluid f. Expected Findings: i. Report of sudden chest pain ii. Indications of respiratory distress 1. Restlessness 2. Cyanosis 3. Dyspnea 4. Pulmonary edema 5. Respiratory arrest iii. Indications of coagulation failure: 1. Bleeding from incisions and venipuncture sites 2. Petechiae and ecchymosis 3. Uterine atony iv. Indications of circulatory collapse 1. Tachycardia 2. Hypotension 3. Shock 4. Cardiac arrest 35. FRIEDMANS CURVE a. Often used to graph the progress of cervical dilation and fetal descent b. Used as a guide to assess and manage the normal progress of labor 36. ABNORMAL FETAL POSITION CARE a. Encourage woman to assume positions that favor fetal rotation and descent and reduce back pain i. Sitting, kneeling, or standing while leaning forward ii. Rocking the pelvis back and forth while on hands and knees (encourages rotation) iii. Side-lying iv. Squatting (in second stage of labor) v. Lunging by placing one foot in a chair with the foot and knee pointed to that side 37. SOUFFLE a. Uterine souffle or placenta soufflé i. A soft, blowing sound that can be heard by a doppler or stethoscope over a pregnant uterus. 38. POSTPARTUM PHYSIOLOGICAL ADAPTIONS a. Main goal during immediate postpartum period is to prevent postpartum hemorrhage b. Postpartum period, (Puerperium) includes physiological and psychological adjustments i. Begins after delivery of placenta and ends when body returns to the prepregnant state. ii. Approximately 6 weeks. c. Greatest risks during the postpartum period are hemorrhage, shock, and infection. d. Menstruation i. Different timing for lactating and nonlactating women 1. Lactating women 1. Serum prolactin levels remain elevated and suppress ovulation. 2. Return of ovulation is influenced by breastfeeding frequency, the length of each feeding and use of supplementation. 2. Nonlactating women 1. Prolactin declines and reaches the prepregnant level by the third week postpartum 2. Ovulation occurs 27 to 75 days after birth. 3. Menses resume by 4 to 6 weeks postpartum. e. Procedures: i. Rh-negative mothers: 1. RHO(D) immune globulin (RhoGAM) is administered within 72 hr to women who are Rh-negative and gave birth to infants who are Rh- positive to prevent sensitization in future pregnancies. ii. Kleihauer-Betke test 1. Determines amount of fetal blood in maternal circulation if a large fetomaternal transfusion is suspected. 2. If 15 mL or more of fetal blood is detected, the mother should receive an increased RhoGAM dose. iii. CBC 1. Monitoring of Hgb, Hct, WBC and platelet counts. 39. POSTPARTUM ASSESSMENT a. B – Breasts b. U – Uterus (fundal height, uterine placement, and consistency) c. B – Bowel and GI function d. B – Bladder function e. L – Lochia (color, odor, consistency, and amount [COCA]) f. E – Episiotomy (edema, ecchymosis, approximation) g. Vital signs, to include pain assessment h. Teaching needs 40. THERMOREGULATION a. Postpartum chill i. Occurs in the first 2 hr puerperium ii. Normal unless it’s accompany with fever iii. Related to a nervous system response, vasomotor changes, a shift in fluids, and/or the work of labor 41. FUNDUS a. Immediately after delivery, fundus should be firm, midline with the umbilicus, and approximately at the level of the umbilicus b. Every 24 hr, the fundus should descend approximately 1 to 2 cm. 42. UTERINE INVOLUTION a. Administer oxytocics IM/IV after placenta is delivered to promote uterine contractions and to prevent hemorrhage. i. Oxytocin (Pitocin) ii. Methylergonovine maleate (Methergine) iii. Carboprost tromethamine (Hemabate) iv. Misoprostol (Cytotec), a prostaglandin. b. Encourage emptying of the bladder every 2 to 3 hr to prevent possible uterine displacement and atony. 43. LOCHIA a. Three stages of lochia i. Lochia rubra 1. Bright red color 2. Bloody consistency 3. Fleshy odor 4. May contain small clots 5. Transient flow increases during breastfeeding and upon rising. 6. Lasts 1 to 3 days after delivery. ii. Lochia serosa 1. Pinkish brown color 2. Serosanguinous consistency 3. Lasts from approximately day 4 to day 10 after delivery iii. Lochia alba 1. Yellowish, white creamy color 2. Fleshy odor 3. Lasts from approximately day 11 up to and beyond 6 weeks postpartum. iv. Abnormal lochia 1. Excessive spurting of bright red blood from the vagina 1. Possibly indicating a cervical or vaginal tear 2. Numerous large clots and excessive blood loss 1. Saturation of one pad in 15 min or less 2. May indicate hemorrhage 3. Foul odor, which is suggestive of infection. 4. Persistent lochia rubra in the early postpartum period beyond day 3 1. May indicate retained placental fragments. 5. Continued flow of lochia serosa or alba beyond the normal length of time 1. May indicate endometritis, especially if it is accompanied by fever, pain, or abdominal tenderness. 44. BREASTS a. Secretion of colostrum (during pregnancy & 2-3 days postpartum) b. Milk is produced 2 to 3 days after the delivery of the newborn. c. Complications: i. Indications of mastitis 1. Infection in a milk duct of the breast with concurrent flulike symptoms d. Allow infant to nurse on demand i. About 8 – 12 times in 24-hr period. e. Suppression of lactation is necessary for clients who are not breastfeeding. i. Avoid breast stimulation and running warm water over the breasts for prolonged periods until no longer lactating. 45. CARDIOVASCULAR/FLUID/HEMATOLOGIC STATUS a. Decrease in blood volume: i. Blood loss during childbirth 1. Vaginal delivery (uncomplicated): average blood loss is 500 mL 2. Cesarean birth: average blood loss is 1,000 mL4 ii. Diaphoresis and diuresis of the excess fluid accumulated during the last part of the pregnancy. 1. Loss occurs within the first 2 to 3 days post-delivery. 46. THROMBOSIS a. Encourage early ambulation to prevent venous stasis and thrombosis. b. Apply antiembolism hose to the client’s lower extremities if high risk for developing venous stasis and thrombosis. i. Hose should be removed as soon as the client is ambulating. 47. URINARY SYSTEM a. Urinary retention secondary to loss of bladder elasticity and tone and/or loss of bladder sensation resulting from trauma, medications, or anesthesia. b. distended bladder as a result of urinary retention i. Can cause uterine atony and displacement to one side, usually to the right. ii. The ability of the uterus to contract is also lessened. c. Postpartal diuresis with increased urinary output begins within 12 hr of delivery. i. Excessive urine diuresis (1,500 to 3,000 mL/day) is normal within the first 2 to 3 days after delivery. d. Assess the client’s ability to void every 2 to 3 hr i. Perineal/urethral edema may cause pain and difficulty in voiding during the first 24 to 48 hr 48. IMMUNE SYSTEM a. Review rubella status i. Client who has a titer of less than 1:8 is administered a subcutaneous injection of rubella vaccine or a measles, mumps, and rubella vaccine during the postpartum period to protect a subsequent fetus from malformations. ii. The client should not get pregnant for 1 month following the immunization. b. Tetanus-diphtheria-acellular pertussis and varicella c. Hepatitis B i. Newborns born to infected mothers should receive the hepatitis B vaccine and the hepatitis B immune globulin within 12 hr of birth. d. Rhogam: Rh negative mother with Rh positive baby 49. PHASES OF MATERNAL ROLE a. Dependent: taking-in phase i. First 24 to 48 hr ii. Focus is on meeting personal needs iii. Rely on others for assistance iv. Excited, talkative; need to review birth experience with others b. Dependent-independent: taking-hold phase i. Begins on day 2 or 3; lasts up to 10 days to several weeks ii. Focus on baby care and improving care-giving competency iii. Want to take charge but need acceptance from others iv. Want to learn and practice c. Interdependent: letting-go phase i. Focus on family as a unit ii. Resumption of role (intimate partner, individual) 50. SEXUAL ACTIVITY a. Resume sexual activity once all vaginal bleeding has stopped and the incision has healed b. Can take 2 to 6 weeks. c. Highly recommended that the client wait until 6 week PP. 51. POSTPARTUM DANGER SIGNS a. Provide client education on danger signs to report to the provider: b. Chills or fever greater than 38° C (100.4° F) for 2 or more days. c. Change in vaginal discharge with increased amount, large clots, change to a previous lochia color, such as bright red bleeding, and a foul odor. d. Postpartum depression is when the client feels apathy toward the infant, cannot provide self- or infant-care, or has feelings that she might hurt herself or her infant. e. Episiotomy, laceration, or incision pain that does not resolve with analgesics, foul- smelling drainage, redness, and/or edema. f. Pain or tenderness in the abdominal or pelvic areas that does not resolve with analgesics. g. Breast(s) with localized areas of pain and tenderness with redness and swelling, and/or nipples with cracks or fissures. h. Calves with localized pain and tenderness, redness, and swelling. A lower extremity with either areas of redness and warmth or coolness and paleness. i. Postpartum depression is when the client feels apathy toward the infant, cannot provide self- or infant-care, or has feelings that she might hurt herself or her infant j. Urination with burning, pain, frequency, urgency; urine that is cloudy or has blood. 52. DEEP VEIN THROMBOSIS a. Thrombophlebitis refers to a thrombus that is associated with inflammation. b. Thrombophlebitis of the lower extremities may be of superficial or deep veins, which are most often of the femoral, saphenous, or popliteal veins. c. The postpartum client is at greatest risk for a deep-vein thrombosis (DVT) that may lead to a pulmonary embolism. d. Risk Factors i. Pregnancy ii. Immobility iii. Obesity iv. Smoking v. Cesarean birth vi. Multiparity vii. Greater than 35 years of age viii. History of previous thromboembolism ix. Diabetes mellitus e. Expected Findings i. Leg pain and tenderness ii. Physical assessment findings iii. Unilateral area of swelling, warmth, and redness iv. Calf tenderness f. Diagnostic procedures (noninvasive) i. Doppler ultrasound scanning U/S ii. Computed tomography CT iii. Magnetic resonance imaging MRI g. Nursing Care i. Prevention of thrombophlebitis 1. Maintain antiembolic stockings until ambulation established. 2. If bed rest is prolonged longer than 8 hr, perform active and passive range of motion to promote circulation in the legs if warranted. 3. Initiate early and frequent ambulation postpartum. 4. Avoid prolonged periods of standing, sitting, or immobility. 5. Have the client elevate her legs when sitting. 6. Tell the client to avoid crossing her legs, which will reduce the circulation and exacerbate venous stasis. 7. Maintain fluid intake of 2 to 3 L each day from food and beverage sources to prevent dehydration, which causes circulation to be sluggish. 8. Tell the client to discontinue smoking, which is a risk factor. 9. Measure the client’s lower extremities for fitted elastic thromboembolic hose to lower extremities. h. Medications i. Heparin 1. Given IV to prevent formation of other clots and to prevent enlargement of the existing clot. ii. Warfarin (Coumadin) 1. Phytonadione (vitamin K), the warfarin antidote, should be readily available for prolonged clotting times. 2. Monitor PT (1.5 to 2.5 times the control level of 11 to 12.5 seconds) and INR of 2 to 3. i. Client Education i. Precautions to take while receiving anticoagulants. ii. Avoid taking aspirin or ibuprofen (increases bleeding tendencies). iii. Use an electric razor for shaving. iv. Avoid alcohol use (inhibits warfarin). v. Brush teeth gently using a soft toothbrush. vi. Avoid rubbing or massaging legs. vii. Avoid periods of prolonged sitting or crossing legs viii. Instruct the client to watch for bleeding from the gums or nose, increased vaginal bleeding, blood in the urine, and frequent bruising. ix. Instruct the client to use birth control to avoid pregnancy due to the teratogenic effects of warfarin. Oral contraceptives are contraindicated because of the increased risk for thrombosis. 53. PULMONARY EMBOLISM a. Occurs when fragments or an entire clot dislodges and moves into circulation. b. Complication of DVT that occurs if the embolus moves into the pulmonary artery or one of its branches and lodges in a lung, occluding the vessel and obstructing blood flow to the lungs. c. Risk Factors for pulmonary embolism are the same as those for DVT. d. Expected Findings i. Apprehension ii. Pleuritic chest pain iii. Dyspnea iv. Tachypnea v. Hemoptysis vi. Heart murmurs vii. Peripheral edema viii. Distended neck veins ix. Elevated temperature x. Hypotension xi. Hypoxia e. Nursing Care i. Place the client in a semi-Fowler’s position with the head of the bed elevated to facilitate breathing. ii. Administer oxygen to the client by mask. iii. Medications prescribed include the medications listed under DVT. iv. Thrombolytic therapy to break up blood clots may be prescribed. v. Alteplase (Activase), streptokinase (Streptase). vi. Similar side effects and contraindications as anticoagulants. 54. LACERATIONS AND/OR HEMATOMAS a. An episiotomy may extend and become a third- or fourth-degree laceration. b. A hematoma is a collection of 250 to 500 mL of clotted blood within tissues that may appear as a bulging bluish mass. i. Hematomas may occur in the pelvic region or higher up in the vagina or broad ligament. c. Pain, rather than noticeable bleeding, is the distinguishable symptom of hematomas. d. Client is at risk for hemorrhage or infection due to a laceration or hematoma. e. Risk Factors i. Operative vaginal birth (forceps-assisted, vacuum assisted birth). ii. Precipitous birth. iii. Cephalopelvic disproportion. iv. Size (macrosomic infant) and abnormal presentation or position of the fetus. v. Prolonged pressure of the fetal head on the vaginal mucosa. vi. Previous scarring of the birth canal from infection, injury, or operation. vii. Clients who are nulliparous are at a greater risk for injury due to firmer and less resistant tissue. viii. Women who have light skin, especially those with reddish hair, have less distensible tissue than women who are dark skin. f. Expected Findings i. Laceration: 1. Sensation of oozing or trickling of blood 2. Excessive rubra lochia (with or without clots) 3. Vaginal bleeding even though the uterus is firm and contracted 4. Continuous slow trickle of bright red blood from vagina, laceration, episiotomy ii. Hematoma 1. Pain 2. Persistent pressure sensation in rectum (urge to defecate) or vagina due to blood leaked into tissue 3. Difficulty voiding 4. Bulging, bluish mass or area of red-purple discoloration on vulva, perineum, or rectum g. Therapeutic procedures i. Repair and suturing of the episiotomy or lacerations is done by the provider. ii. Ligation of the bleeding vessel or surgical incision for evacuation of the clotted blood from the hematoma is done by the provider. 55. POSTPARTUM HEMORRHAGE a. Vaginal birth (uncomplicated) i. Loss of more than 500 mL of blood b. Cesarean birth i. Loss of 1,000 mL or more of blood. c. Risk Factors i. Uterine atony ii. Complications during pregnancy (e.g., placenta previa, abruptio placenta) iii. Precipitous delivery iv. Administration of magnesium sulfate therapy during labor v. Lacerations and hematomas vi. Inversion of uterus vii. Subinvolution of the uterus viii. Retained placental fragments ix. Coagulopathies (DIC) d. Expected Findings i. Increase or change in lochial pattern (return to previous stage, large clots) ii. Uterine atony iii. Blood clots larger than a quarter iv. Perineal pad saturation in 15 min or less v. Constant oozing, trickling, or frank flow of bright red blood from the vagina vi. Tachycardia and hypotension vii. Skin pale, cool, and clammy with loss of turgor and pale mucous membranes viii. Oliguria e. Laboratory tests i. Hgb and Hct ii. Coagulation profile (PT) iii. Blood type and crossmatch f. Complications i. Hypovolemic shock ii. Anemia g. Nursing Care i. Monitor vital signs. ii. Assess for source of bleeding. iii. Assess fundus for height, firmness, and position. If uterus is boggy, massage fundus to increase muscle contraction. iv. Assess bladder for distention: Insert an indwelling urinary catheter to assess the client’s kidney function and obtain an accurate measurement of urinary output. h. Medications i. Oxytocin (Pitocin): 1. Promotes uterine contractions ii. Methylergonovine (Methergine): 1. Assess uterine tone and vaginal bleeding. 2. Do not administer to clients who have hypertension iii. Misoprostol (Cytotec) iv. Carboprost tromethamine (Hemabate): 1. Monitor for adverse reactions 1. Fever 2. Chills 3. Headache 4. Nausea 5. Vomiting 6. Diarrhea 2. Contraindication: 1. Asthma 56. UTERINE ATONY a. Results from the inability of the uterine muscle to contract adequately after birth. b. Can lead to postpartum hemorrhage c. Medications: i. Pitocin ii. Methergine iii. Cytotec iv. Hemabate d. Risk Factors i. Retained placental fragments ii. Prolonged labor iii. Oxytocin (Pitocin) induction or augmentation of labor iv. Overdistention of the uterine muscle 1. Multiparity 2. Multiple gestations 3. Polyhydramnios [hydramnios] 4. Macrosomic fetus) v. Precipitous labor vi. Magnesium sulfate administration as a tocolytic vii. Anesthesia and analgesia administration viii. Trauma during labor and birth from operative delivery (forceps-assisted or vacuum-assisted birth, cesarean birth) e. Expected Findings i. Increased vaginal bleeding ii. Uterus that is larger than normal and boggy with possible lateral displacement on palpation iii. Prolonged lochial discharge iv. Irregular or excessive bleeding v. Tachycardia and hypotension vi. Skin that is pale, cool, and clammy with loss of turgor and pale mucous membranes f. Diagnostic procedures i. Bimanual compression or manual exploration of the uterine cavity for retained placental fragments by the provider ii. Surgical management such as a hysterectomy g. Nursing Care i. Ensure that the client’s urinary bladder is empty. ii. Monitor 1. Fundal height, consistency, and location. 2. Lochia for quantity, color, and consistency. iii. Perform fundal massage if indicated. iv. If the uterus becomes firm, continue assessing hemodynamic status. v. If uterine atony persists, anticipate surgical intervention, such as a hysterectomy. vi. Express clots that may have accumulated in the uterus, but only after the uterus is firmly contracted. 1. It is critical not to express clots prior to the uterus becoming firmly contracted because pushing on an uncontracted uterus can invert the uterus and result in extensive hemorrhage. 57. SUBINVOLUTION OF THE UTERUS a. Uterus remains enlarged with continued lochial discharge i. May result in postpartum hemorrhage. b. Risk Factors: i. Pelvic infection and endometritis ii. Retained placental fragments not completely expelled from the uterus c. Expected Findings: i. Increased vaginal bleeding ii. A uterus that is enlarged and higher than normal in the abdomen relative to the umbilicus. iii. A boggy uterus. iv. Prolonged lochia discharge with irregular or excessive bleeding. d. Laboratory tests i. Blood, intracervical, and intrauterine bacterial cultures to check for evidence of infection and/ or endometritis. e. Diagnostic procedures i. Dilation and curettage (D&C) 1. Performed by the provider to remove retained placental fragments if indicated. f. Nursing Care i. Monitor fundal position and consistency. ii. Monitor lochia for color, amount, consistency, and odor. iii. Monitor vital signs. iv. Encourage the client to use activities that can enhance uterine involution. v. Breastfeeding vi. Early and frequent ambulation vii. Frequent voiding g. Medications i. Oxytocin (Pitocin) 58. INVERSION OF THE UTERUS a. Turning inside out of the uterus b. May be partial or complete. i. Complete inversion 1. Large, red, rounded mass that protrudes 20 to 30 cm outside the introitus ii. Partial inversion 1. Palpation of a smooth mass through the dilated cervix c. Emergency situation that can result in postpartum hemorrhage and requires immediate intervention. d. Risk Factors: i. Retained placenta ii. Uterine atony iii. Excessive fundal pressure iv. Abnormally adherent placental tissue v. Multiparity vi. Fundal implantation of the placenta vii. Extreme traction applied to the umbilical cord viii. Leiomyomas (a benign uterine fibroid tumor) e. Expected Findings i. Pain in lower abdomen ii. Vaginal bleeding iii. Dizziness iv. Low blood pressure v. Pallor f. Diagnostic procedures i. Manual replacement of the uterus into the uterine cavity and repositioning of the uterus by the provider g. Nursing Care i. Visualizing the introitus. ii. Performing a pelvic exam. iii. Maintaining IV fluids. iv. Administering oxygen. v. Stop oxytocin (Pitocin) if it is being administered at the time uterine inversion occurred. vi. Avoid excessive traction on the umbilical cord. vii. Anticipate surgery if nonsurgical interventions and management are unsuccessful. viii. Avoid aggressive fundal massage h. Medications: i. Tocolytic ii. Terbutaline (Brethine) 1. Relaxs the uterus prior to the provider’s attempt at replacement of the uterus into the uterine cavity and uterus repositioning 59. RETAINED PLACENTA a. Placenta or fragments of the placenta remain in the uterus and prevents the uterus from contracting i. Can lead to uterine atony or subinvolution. b. Risk Factors: i. Partial separation of a normal placenta. ii. Entrapment of a partially or completely separated placenta by a constricting ring of the uterus. iii. Excessive traction on the umbilical cord prior to complete separation of the placenta. iv. Placental tissue that is abnormally adherent to the uterine wall. v. Common in preterm births between 20 and 24 weeks of gestation. c. Expected Findings i. Uterine atony, subinvolution, or inversion. ii. Excessive bleeding or blood clots larger than a quarter. iii. The return of lochia rubra once lochia has progressed to serosa alba. iv. Malodorous lochia or vaginal discharge. v. Elevated temperature. d. Laboratory tests i. Hgb and Hct e. Diagnostic procedures i. Manual separation and removal of the placenta is done by the provider. ii. D&C if oxytocics are ineffective in expelling the placental fragments. f. Nursing Care i. Monitor the uterus for fundal height, consistency, and position. ii. Monitor lochia for color, amount, consistency, and odor. iii. Monitor vital signs. iv. Maintain or initiate IV fluids. v. Provide oxygen to the client at 2 to 3 L/min per nasal cannula. vi. Anticipate surgical interventions, such as a hysterectomy, if postpartum bleeding is present and continues. g. Medications i. Oxytocin (Pitocin) 60. POSTPARTUM INFECTIONS a. Complications that may occur up to 28 days following childbirth, or a spontaneous or induced abortion. b. Fever of 38° C (100.4° F) or higher for 2 consecutive days during the first 10 days of the postpartum period is indicative of a postpartum infection and requires further investigation. c. Types of infections: i. Endometritis ii. Mastitis iii. Wound Infections iv. Urinary Tract Infection 61. WOUND INFECTIONS a. Sites of wound infections i. Cesarean incisions ii. Episiotomies iii. Lacerations iv. Any trauma wounds present in the birth canal following labor and birth. b. Expected Findings: i. Wound warmth ii. Erythema iii. Tenderness iv. Pain v. Edema vi. Seropurulent drainage vii. Wound dehiscence (separation of wound or incision edges) viii. Evisceration (protrusion of internal contents through the separated wound edges) ix. Temperature greater than 38° C (100.4° F) for 2 or more consecutive days 62. URINARY TRACT INFECTION a. Common postpartum infection, secondary to bladder trauma b. Incurred during the delivery or a break in aseptic technique during bladder catheterization. c. Risk Factors: i. Postpartal hypotonic bladder and/or urethra (urinary stasis and retention) ii. Epidural anesthesia iii. Urinary bladder catheterization iv. Frequent pelvic examinations v. Genital tract injuries vi. History of UTIs vii. Cesarean birth d. Expected Findings i. Reports of urgency, frequency, dysuria, and discomfort in the pelvic area ii. Fever iii. Chills iv. Malaise v. Change in vital signs, elevated temperature vi. Urine (cloudy, blood-tinged, malodorous, sediment visible) vii. Urinary retention viii. Pain in the suprapubic area ix. Pain at the costovertebral angle (pyelonephritis) e. Diagnostic procedures i. Urinalysis for WBCs, RBCs, protein, bacteria 63. ENDOMETRITIS a. Infection of the uterine lining or endometrium. b. Most frequently occurring puerperal infection. c. Usually begins on 2nd to 5th postpartum day i. Generally starting as localized infection at placental attachment site & spreading to include the entire uterine endometrium. d. Risk Factors i. Cesarean birth ii. Retained placental fragments and manual extraction of the placenta iii. Prolonged rupture of membranes iv. Chorioamnionitis v. Internal fetal/uterine pressure monitoring vi. Multiple vaginal examinations after rupture of membranes vii. Prolonged labor viii. Postpartum hemorrhage e. Expected Findings i. Puerperal infections ii. Flulike symptoms such as body aches, chills, fever, and malaise iii. Anorexia and nausea iv. Pelvic pain v. Chills vi. Fatigue vii. Loss of appetite viii. Elevated temperature of at least 38° C (100.4° F) for 2 or more consecutive days 1. Typically on the 3rd to 4th day postpartum ix. Tachycardia x. Uterine tenderness and enlargement xi. Dark, profuse lochia xii. Lochia that is either malodorous or purulent 64. MASTITIS a. Infection of the breast involving the interlobular connective tissue i. Usually unilateral ii. May progress to an abscess if untreated b. Most commonly in mothers breastfeeding for the first time and well after the establishment of milk flow i. Usually 2 to 4 weeks after delivery. c. Causes i. Staphylococcus aureus is usually the infecting organism ii. Milk stasis from a blocked duct iii. Nipple trauma and cracked or fissured nipples iv. Poor breastfeeding technique with improper latching of the infant onto the breast v. Decrease in breastfeeding frequency due to supplementation with bottle feeding vi. Poor hygiene and inadequate handwashing when handling perineal pads and touching the breasts vii. Expected Findings 1. Painful or tender, localized hard mass, and reddened area usually on one breast 2. Chills 3. Fatigue 65. BREASTFEEDING a. Purified lanolin cream is an over-the-counter product that is recommended for the treatment of sore nipples. b. Breast shells are recommended for clients who are postpartum and have sore nipples i. They are used as a barrier to keep clothing away from the nipples and to allow air to circulate. c. A snug-fitting support bra is recommended to suppress lactation for the client who is not breastfeeding. i. The bra prevents strain on the breast muscles and places the breasts in proper alignment to decrease engorgement. 66. POSTPARTUM BLUES a. Can occur in approximately 50% to 70% of women during the first few days after birth b. Generally continues for up to 10 days. c. Expected Findings i. Tearfulness ii. Insomnia iii. Lack of appetite iv. Feeling of letdown. v. Intense fear and/or anxiety vi. Anger vii. Inability to cope with the slightest problems and become despondent d. Postpartum blues typically resolves in 10 days without intervention. 67. POSTPARTUM DEPRESSION a. Occurs within 6 months of delivery b. Expected Findings i. Persistent feelings of sadness ii. Intense mood swings c. Occurs in 10% to 15% of new mothers d. Usually does not resolve without intervention e. Similar to nonpostpartum mood disorders. 68. POSTPARTUM PSYCHOSIS a. Develops within the first 2 to 3 weeks of the postpartum period. b. History of bipolar disorder are at a higher risk. c. Expected Findings i. Severe symptoms ii. Confusion iii. Disorientation iv. Hallucinations v. Delusions vi. Obsessive behaviors vii. Paranoia viii. Client may attempt to harm herself or her infant d. Risk Factors i. Hormonal changes with a rapid decline in estrogen and progesterone levels ii. Postpartum physical discomfort and/or pain iii. Individual socioeconomic factors iv. Decreased social support system v. Anxiety about assuming new role as a mother vi. Unplanned or unwanted pregnancy vii. History of previous depressive episode viii. Low self-esteem ix. History of domestic violence 69. PHYSICAL RESPONSE OF NEWBORN TO BIRTH a. Adjustments to extrauterine life occur as a newborn’s respiratory and circulatory systems are required to rapidly adjust to life outside of the uterus b. The establishment of respiratory function with the cutting of the umbilical cord is the most critical extrauterine adjustment as air inflates the lungs with the first breath. c. Circulatory changes i. The three shunts (ductus arteriosus, ductus venosus, and foramen ovale) functionally close during a newborn’s transition to extrauterine life with th