Studied by 2 peopledelivery of the placenta
what indicates the third stage of labor?
contraction of the uterus (globular shape), gush of blood, lengthening of cord, vaginal fullness/urge to push
what signs indicate that the placenta has separated?
pitocin, methergine, hemabate, cytobtec
medications that may be administered after delivery of the placenta include -
fundal massage, breastfeeding
what can stimulate the release of oxytocin if medication administration are not capable of being administered?
1-4 hours after birth
how long is the 4th stage of labor?
q15 for the first hour, and q30 for the next hour (temperature hourly)
how often do you assess vitals in the 4th stage of labor?
1st degree perineal laceration
limited to the fourchette, perineal skin, and vaginal mucous membrane
2nd degree perineal laceration
involves the perineal skin, vaginal mucous membrane, underlying fascia, and muscle of the perineal body and may extend upward on one or both sides of the vagina
3rd degree perineal lacerations
extends through the perineal skin, vaginal mucous membranes, and perineal body and involves the anal sphincter; may extend up the anterior wall of the rectum
4th degree perineal laceration (3rd degree laceration with a rectal wall extension)
+ extends through the rectal mucosa to the lumen of the rectum
uterine endometrium
what layer of the uterus does the placenta usually attach?
placenta accrete
chorionic villi attach directly to the uterine myometrium; associated with maternal hemorrhage and failed placental separation after birth
placenta increta
myometrium is invaded by placenta
placenta percreta
myometrium is penetrated by placenta; high incidence of abdominal hysterectomy
succenturiate placenta
accessory lobes develop on the placenta and can cause hemorrhage due to retained placenta parts
circumvallate placenta
a double fold of chorion and amnion from a ring around the umbilical cord on the fetal side of the placenta
late term fetal loss, antepartum hemorrhage and preterm labor, IUGR prematurity and fetal death
fetal risks associated with circumvallate placenta
battledore placenta
the umbilical cord is inserted at or near the placental margin
increased PTL and bleeding, prematurity, non-reassuring FHTs may occur
fetal risk associated with battledore placenta
velamentous insertion
vessels of the umbilical cord divide some distance from the placenta and placental membranes
hemorrhage, nonreassuring FHTs and hemorrhage in the fetus
risks associated with velamentous insertion of the umbilical cord -
30 minutes
at what point following birth will intervention be needed if the placenta has not delivered?
titrate oxytocin; manual removal of the placenta
what are interventions to help remove the placenta?
uterine atony
fundus is boggy, difficult to find, above where expected; lochia is copious, bright red and clotty - what do you suspect?
lacerations
firm uterus, bright red bleeding, continuous stream of blood without clots - what do you suspect?
hematomas
pain, unilateral purplish discoloration, vaginal fullness, rectal pressure, difficulty voiding - what do you suspect?
uterine inversion
pain, hemorrhage, shock, unable to palpate uterus in abdomen - what do you suspect?
fundal massage, medications, IV fluids, uterine tamponade balloon, ligation of uterine vessels, hysterectomy
possible treatments for uterine atony -
call provider to assess repair; hold pressure if bleeding is copious
intervention for lacerations
pain management; ice; sitzbaths, surgical evacuation
interventions for hematomas
check for amount of bleeding
what is the FIRST intervention of uterine inversion?
check fundus and begin fundal massage; call for help, get vital signs, and observe for signs and symptoms of hemorrhagic shock
what are follow up interventions for uterine inversion
pitocin, methergine, misoprostol, hemabate, dinoprostone
what medications are given for uterine atony?
fluids; placement of uterus back in abdominal cavity by MD; administration of oxytocic agents after replacement; treat signs and symptoms of shock
treatment of uterine inversion
color (circulatory changes will fix this)
what part of the Apgar score is commonly not a 2?
97.9
normal newborn temperature:
110-160
normal newborn heart rate -
30-60
normal newborn RR?
precipitous delivery
labor that is less than 3 hours -
postpartum hemorrhage, uterine rupture, lacerations, amniotic fluid embolus
risk of precipitous delivery for the mother -
facial bruising/swelling, respiratory distress, intercranial trauma
risks for fetus associated with precipitous delivery -
rubra
lochia appearance the first 2-3 days following birth
serosa
lochia appearance days 3-10
alba
lochia appearance from day 10 to the cervix closes
70-75 days (for nonbreastfeeding mothers) or 6 months (for breastfeeding mothers)
when does menstruation normally return to normal?
bruises, blisters, cracks, bleeding nipples, engorged breasts
what is an abnormal finding in breasts during a postpartum exam?
boggy, elevated, and deviated
abnormal finding in the uterus in a postpartum assessment
hypoactive
what kind of bowel signs are normal in a postpartum assessment
urinary retention or incomplete emptying
abnormal findings for the bladder during a postnatal assessment?
large, copious clots
abnormal findings for lochia
edema, hematomas, s/s symptoms of edema
what are some signs of infection following an episiotomy
500 more calories than pre pregnancy
how many extra calories should a person consume while breastfeeding?
no
can I use tampons for my postpartum bleeding?
once the bleeding completely stops
am I allowed to take tub bath?
occurs 24 days to 6 weeks postpartum
postpartum hemorrhage
arrest of the involution process (retained placental fragments, placenta acreta, infection, fibroids)
what are common causes of late hemorrhage
grand multiparity, uterine overdistension, C-section, fibroids
risk factors for late hemorrhage
postpartum hemorrhage
patient presents with - prolonged lochia discharge, irregular/excessive uterine bleeding, uterus is larger and softer than normal for the particular period of puerperium, s/s symptoms of infection, pain at uterine border
manual removal of any retained placental fragments, methergine, oxytocin, antibiotics
interventions for postpartum hemorrhage
fever, malaise, abdominal pain, foul-smelling lochia, larger than expected uterus, tachycardia, REEDA
s/s of reproductive tract infections
baby blues
feelings of sadness, anxiety, crying, difficulty sleeping, loss of appetite, symptoms resolve in a few days
postpartum depression
Anxiety, Irritability (key indicator), Poor concentration, Forgetfulness, Sleep difficulties, Appetite change, Fatigue, Tearfulness, Statements indicating feeling failure and self-accusation
postpartum psychosis
rapid onset of bizarre behavior, auditory or visual hallucinations, paranoid or grandiose delusions, elements of delirium or disorientation. This increases the risk of infanticide or suicide
magnesium sulfate to treat seizures
treatment for preeclampsia during postpartum preeclampsia
increased amounts of certain blood-clotting factors
postpartum thrombosis cause
postpartum thrombocytosis
release of thromboplastin substances from the decidua, placenta, and membranes; increased amounts of fibrinolysis inhibitors
virchow triad
hypercoagulability of blood, venous stasis, and injury to the epithelium of the blood vessel
postpartum thrombosis
patient presents with - pain in the leg, inguinal area, or lower abdomen, edema, temperature changes, and pain upon palpation
HIV/AIDS, active tuberculosis, varicella, human T-lymphocyte virus 1, herpes on the breast, illicit drug use, smoking, certain prescription medications, mother has breast cancer, baby has galactosemia
what are some contraindications for breastfeeding?
on demand
when should a breastfed baby be fed?
every 1.5 to 3 hours with 8 to 12 feedings per day
how often should a bottle fed baby be fed?
mechanical stimuli
chest recoil as the chest is compressed in the birth canal
chemical stimuli
first breath is inspiratory gasp that is triggered by increased PCO2 and decrease pH and PO2
thermal stimuli
significant decrease in environmental temperature after birth stimulates skin nerve endings and the newborn responds with rhythmic respirations
increases blood volume by 50%
what is the benefit of delayed cord clamping?
convention
cool air passing over the baby removes their heat
radiation
bassinet is near a large window when its cold outside; placing cold objects within the crib
evaporation
wetness on skin; amniotic fluid or wet towels holding the dampness
conduction
cold objects touching the infant; cold stethoscopes, placing infant on cold surface
physiologic jaundice
accelerated destruction of fetal RBCs and increased reabsorption of bilirubin by the liver
normal
is physiologic jaundice normal or abnormal?
after 24 hours
when does physiologic jaundice occur?
maintain newborn temperature, make sure feeds are adequate, make sure newborn is stooling and voiding, indirect sunlight
what would you teach a mother taking home a newborn with physiologic jaundice?
vitamin k
what medication is given to help the newborn create clotting factors?
IM dose of .5 mg
how much vitamin K is given to a newborn?
4 weeks
how long dose newborn passive immunity last in the newborn
IgG immunoglobulin crosses the placenta
how dose a newborn acquire passive immunity?
breastfeeding
how does a newborn acquire active immunity?
IgA and IgM
what immunoglobins are acquired by the newborn for active immunity?
passive immunity is only acquired during 3rd trimester
why are pre-term babies more at risk for infection?
1 and 5 minutes
when should an APGAR be done?
cephalohematoma
collection of blood between the cranial bone and periosteal membrane
caput succedaneum
collection of fluid, swelling of the scalp
65-85/45-55
normal BP
110-160
normal pulse
30-60
normal RR
greater than 20 seconds
when is apnea concerning?
10% of birth weight
what is the max amount of weight loss allowed?
increased calorie consumption, low blood sugar
what occurs in an infant who is too cold?
the first five days should equal the number of wet diapers
how much should an infant void?
Note
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