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High Risk OB

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on 1 December 2014

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Transcript of High Risk OB

High Risk OB
Hematologic and
Cellular function

Metabolic: Internal Regulation-
HELLP is one of the .. causes of liver failure
DIC
HELLP=hemolysis,
elevated liver enzymes, low platelets

Pre-eclampsia
Fluid and Electrolytes
Kidneys

Placental abruption
Hemorrhage
HTN
Stroke
Eclampsia
Seizures
Neurologic
Hypovolemic shock
Tissue Perfusion
Gestational Diabetes
Effects on/of Diabetes
London pp. 306-308

Metabolic: Nutrition
OB Review
Monitor and record vital signs
Assess lung sounds and WOB
Monitor oxygen saturation with pulse oximetry.
Implement cardiac monitoring as indicated per facility guidelines.
Assess fundus and lochia.
Evaluate abdominal dressing.
Monitor level of consciousness.

Post-op C-section Assessment

Fundal Assessment

Head to Toe Assessment-beginning of shift
Focused Postpartum Assessment
Maternal vital signs
BUBBLESHE
Lower extremities, pain, rest, nutrition
Teaching needs
At risk: Clonus, reflexes, assess for headache, visual changes, epigastric pain

Postpartum Assessment

Postpartum Assesments

Hgb and Hct-difficult to determine in first 2 days 2nd to changing blood volume-1/2 RBC gained lost in first 24 hours
As ECF excreted, hemoconcentration occurs-rise in hematocrit; if drop in Hct abnormal blood loss-expect 2-3% drop in Hct=500ml blood loss
2-5 days mobilization of IF leads to slight increase in plasma volume-hemo dilution by end of week
Platelets decrease 2nd to placental separation-start to increase by 3-4 day, normal by 6th pp week

CVS: Changes in Blood Values

Postpartum period:
From delivery of placenta to the return of the reproductive system to the non-pregnant state
Usually 6 – 8 weeks
Also called the 4th trimester of pregnancy

Physiological Changes

Monitor and record IV site, intake and output.
Auscultate for bowel sounds in all four quadrants.
Assess the amount, color, and characteristics of urine in foley catheter bag.
Teach and assist the woman with deep breathing exercises and incentive spirometry.
Monitor for side effects of anesthesia.
Assess for pain and the need for additional pain medication.

Post-op C-section Assessment

Care following Cesarean Section

Identify type and severity of pain.
Confirm location and extent of discomfort.
Differentiate normal postpartum pain from complications.
Be alert for cultural components of pain expression.
Common sources of pain include:
Episiotomy and/or laceration repairs, Cesarean incision site pain, Hemorrhoids, Postpartum uterine contractions, Breast engorgement, Gas pain

Pain Assessment

Lower extremities for DVT-Homan’s sign
Pain
Rest/sleep
Nutrition

Postpartum Assessment

Apply ice packs for 12 – 24 hours
30 minutes on…
30-60 minutes off…
Administer analgesics and topical agents
After 24 hours, offer sitz baths 3 times/day

Perineal Care

Cesarean incisions, episiotomies and laceration repairs can be evaluated using REEDA:
R – redness
E – edema
E – ecchymosis
D – drainage
A - approximation

REEDA

What is included in the perineal assessment?

Perineal Assessment

Amount, character, and color
Changes in Lochia that causes concern
Clots
Foul smelling
Saturating more than one pad/hour
Persistent lochia rubra
Continuous bright red bleeding


Lochia Assessment

Volume of lochial flow based on amount of blood on pad (1-2 hrs):
Scant < 1 inch
Small < 4 inches
Moderate < 6 inches
Heavy - saturated

Lochia Assessment

How would you assess the bladder and bowels?

What are your primary concerns if the bladder is full?

Bladder and Bowel

What are some abnormal findings in breast assessment?

Assessment of Breasts

General condition of breasts
Color
Comfort
Condition of nipples (flat, inverted, everted)
Consistency (soft, firm, full, engorged)
Assessment of latch-on

Assessment of Breasts

B= Breasts
U= Uterus
B= Bladder
B= Bowel
L= Lochia
E= Episiotomy/lacerations
S= Support Systems
H= Hematoma/perineum/hemorrhoids
E= Emotional response
Also VS, lower extremities, pain, rest, nutrition

Focused Postpartum Assessment

Treatment should be guided by the severity of illness:
Primary prevention
Early recognition and timely diagnosis and intervention-pp assessment tools
Secondary prevention
Psychosocial strategies – peer support groups
Psychological strategies – interpersonal therapy
Pharmacologic management
Electroconvulsive therapy
Combination therapy

Treatment of PPD

Postpartum depression occurs in about
10 – 15% of all postpartum patients.
Symptoms include:
Intense, pervasive sadness
Labile mood swings
Intense fear
Irritability which may progress to violent outbursts
Rejection of infant
Obsessive thoughts

Postpartum Depression

Three phases:
◆ Taking-In Phase (dependent)
◆ Taking-Hold Phase (independent)
◆ Letting-Go Phase (interdependent)

Maternal Psychological Adaptations

Weight loss-initial loss 10-12 lbs , another 5 lbs after diuresis
Postpartal chill
Postpartal diaphoresis

Other Postpartum Physiological Adaptations

Headache:
R/O postpartum onset of preeclampsia
R/O spinal headache
Fluid shifts/stress
Interventions:
Dim lighting
Decrease noise levels
Limit visitors
Administer analgesia as ordered

Neurologic Changes

Risk of over distention, incomplete bladder emptying
Increased bladder capacity
Swelling/bruising of tissue around urethra
Decreased sensitivity to fluid pressure
Decreased sensation of bladder filling
Anesthetic block inhibits neural functioning
Oxytocin has antidiuretic effect-after done rapid bladder filling
Puerperal diuresis-to eliminate 2000-3000 mL of ECF causes rapid bladder filling
Adequate bladder elimination immediate concern otherwise lead to stasis, UTI, uterine atony and hemorrhage
Dilated ureters and renal pelvis return to pre-pregnant state by end of 6th week

GU Changes

Bowels sluggish 2nd to lingering effects of progesterone, decreased muscle tone, labor and birth process
May refuse/delay bowel movement for fear of pain leads to constipation
Hunger common
C-sx gas pain

GI Changes

White blood cells (WBCs) nonpathologic leukocytosis 25-30,000-normal by end of 1st week
ESR increases-inflammation
Coagulation factors-continues and with (trauma, immobility, sepsis) risk of DVT-reduce by early mobilization
Most blood values return to pre-pregnant levels by 4 weeks-except diameter of deep veins prolonged risk of DVT in first 6 weeks


CVS: Changes in Blood Values

Maternal hypervolemia protects mother from excessive blood loss
Changes in blood volume after birth depend on the amount of blood loss at delivery and the amount of ECF excreted.
Diuresis in first 2-5 days assists to decrease the extracellular fluid
CO declines by 30% in first 2 weeks, reaches normal levels by 6-12 weeks
Decreases in plasma volume reach nonpregnant levels by 4-6 weeks postpartum



CVS: Blood Volume Changes

After placenta expelled-drop in progesterone milk production triggered (progesterone level in pregnancy from placenta suppresses lactation)
Elevated serum prolactin levels
Prolactin levels in lactating women remain elevated for 6 weeks after delivery and are influenced by:
❖ Frequency of feedings
❖ Duration of feedings
❖ Need for supplementation

Hormonal Changes

Nonlactating women:
Within 4-8 weeks of delivery-25% preceded by ovulation
Lactating women:
15% by 6 weeks
45% by 6 months
40% when weaning is complete

Infant suckling-alters FSH (prolactin) &GnRH-amenorrhea
(Not reliable means of contraception)

Return of ovulation also associated with rise in serum progesterone (initial drop after placenta expelled)


Return of Menstruation/Ovulation

Soft tissue in and around perineum may be edematous and bruised
Episiotomy or laceration-repaired should be intact and well approximated-initial healing 2-3 weeks, complete healing 4-6 months
Ecchymosis or hematoma may occur
Hemorrhoids

Perineal changes

Edematous and may be bruised-trauma
Lacerations may occur-watch for bleeding
Return to smaller dimensions by 3-4 weeks
Tone and contractibility improve by perineal tightening exercises-Kegel
Lacerations-1st to 4th degree
1st limited perineal skin, vag mucous membranes
2nd above+ fascia +muscles+extend up vagina
3rd extends and involves anal sphincter
4th same as 3rd but includes through rectal wall

Vaginal changes

Flabby, formless, appear bruised
May have lacerations- can cause bleeding bright red and continuous
Shape is permanently changed by the firs childbearing-need to refit diaphragm or cervical cap if used for contraception


Cervical changes

Normal blood loss from a vaginal delivery usually does not exceed 500 mL.
If blood loss is excessive, weigh linens and pads for a more accurate estimation.
1 milliliter of blood = approximately 1 gram in weight

Estimating Blood Loss

Lochia-debris/discharge

Atonic and well-contracted uterine muscle

Necessary to achieve hemostasis at the placental site-exfoliation placental site heals 6 weeks
Painful intermittent uterine contractions
Stronger and more frequent in the multiparous woman

Stimulated by:
❖ Release of oxytocin from posterior pituitary
❖ Administration of exogenous oxytocin
❖ Breastfeeding-increased discomfort associated with breastfeeding

Contractions of “After Pains”

Breasts
Uterine involution-Fundal position
Lochia
Cervical changes
Vaginal changes
Perineal changes
Return of ovulation and menstruation
Hormonal changes

Reproductive System

Reproductive System
CVS
Musculoskeletal-Abdomen
GI
GU
Neuro
Other adaptations: after pains, weight loss, post partal chill, post partal diaphoresis

Physiological Changes

The Postpartum Woman: Physiological and Psychological Changes

Describe the normal physiologic changes occurring during the postpartum period.
Differentiate normal from abnormal physiologic changes during the postpartum period.
Differentiate normal from abnormal postpartum emotional changes.
Identify the components of a focused postpartum assessment and cares for the postpartum mother.
Develop a nursing management care plan based on primary concerns identified from differentiating abnormal from normal findings in the postpartum period.


Objectives

Fundal check includes tone, height, and location

Fundal Assessment

Important data needed to care for patient:
OB hx including gest. age, Gravida and TPAL
Prenatal lab results
Blood type, Rh (Rh negative mom, Rh pos fetus)
Hep B
Rubella
GBS status
Date/time/ type of delivery/EBL=estimated blood loss
Mother’s current Hgb

Postpartum Assessment

Postpartum psychosis
Hallucinations, delusions, agitation, inability to sleep, bizarre or irrational behavior
Bipolar II disorder
Major depressive episodes with recurrent hypomania
Postpartum Depression (PPD)
Postpartum Blues

Postpartum Emotional Changes

Abdominal muscles protrude during the 1st several postpartum days.
Diastatis recti of the abdominal rectus muscles may be common but resolve within about 6 weeks.

Abdominal Wall Changes

Temp up to 38 *C normal 2nd to exertion and dehydration of labor, also increase when milk comes in
Transient rise in BP for few days, decrease may be physiologic readjustment do decreased intrapelvic pressure or hemorrhage
Orthostatic hypotension first 48 2nd to abdominal engorgement
HR 50-70 bradycardia common 6-10 days 2nd to decreased cardiac effort, dec blood volume, increased stroke volume. HR > 100 indicates hypovolemia, infection, fear, pain

CVS: Changes in Vital Signs

Volume of lochial flow based on amount of blood on pad (1-2 hrs):
Scant < 1 inch
Small < 4 inches
Moderate < 6 inches
Heavy - saturated

Lochia Assessment

Within 12 hours of birth, the fundus may be palpated at 1 cm above the umbilicus.
The fundus height descends 1 – 2 cm per day.
By two weeks postpartum, the fundus should not be palpable.

Uterine Involution

Masses may be palpable
Colostrum may be expressed
Breast firmness/fullness
Tenderness present

Breasts

C-section

Q 15 minutes x 8 (2 hours)
Upon pp admission
Q 4 hours x 2
Once/shift


Vaginal Delivery

Postpartum Assessment-Follow facility guidelines

Click into D2L under the OB Content tab to access all OB content review powerpoints. Review these along with Complications in Pregnancy and High Risk Newborn ppts. as you work your way through this prezi.
Magnesium Sulfate
Tx to prevent seizures
Neuroprotection

Amniotic Fluid Embolism
DVT
Pulmonary Embolism

Postpartum
Uterine atony
Placental fragments

Risk Factors:
Prenatal
Intrapartal

Preeclampsia/HELLP Syndrome video:


Evidenced Based Practice Guidelines:
http://www.guideline.gov/content.aspx?id=48055&search=pre-eclampsia
http://www.guideline.gov/content.aspx?id=24122&search=hellp+syndrome#Section420
Preeclampsia/HELLP Syndrome Links

Read London Chapter 16 pp. 338-348
Includes all pregnancy hypertensive disorders and DIC
HELLP Syndrome article:
http://pearl.stkate.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=rzh&AN=2010617749&site=ehost-live



Pre-eclampsia and HELLP syndrome readings


Examples (London, 2011, pp. 387-388)
Abnormal presentation
Multiple gestation
Polyhydramnios/Oligohydramnios
Meconium stained amniotic fluid
PROM
Post dates
Diabetes
Preeclampsia
AIDS/STIs
Induction, prolonged labor


Intrapartal High Risk Factors

Examples (London, 2011, pp. 203-204)
Poor diet, underweight, overweight
Age < 16 or >35
Smoking
Use of addicting drugs, alcohol
DM, HTN, Anemia
Thyroid disorders, renal disease
Multiparity >3, multiple gestation
Previous C-sx, Rh factor negative
Prenatal labs-GBS status positive


Prenatal High Risk Factors

Fluid & Electrolytes/Renal Function from the perspective of High Risk OB complication of Severe Pre-eclampsia
Refer to London, pp. 342-345
List relevant nursing assessments when caring for a pregnant woman with pre-eclampsia
that have to do with fluid/electrolytes and renal function.
For each listed assessment-explain the pathophysiology of pre-eclampsia that relates to these assessments and the concern.


Fill in the blanks with increased vs decreased
Renal perfusion is________
GFR is _______
Cr, BUN, and uric acid_______
Urine output____________
Na retention________
Along with Na, fluid retention________
Causing an ______ in extracellular volume and edema


allows large protein, primarily albumin, to escape into the urine, decreasing serum albumin
causes fluid shifts from intravascular to extravascular space
causes decreased plasma colloid osmotic pressure, resulting in further fluid shifts from intravascular into interstitial spaces and edema
Risk of pulmonary edema


Vasospasm and injury to endothelial cells
Damaged capillary walls of the glomerular endothelial cells
Decreased serum albumin causes
risk increases secondary to magnesium sulfate administration as side effect

Match the above statements with the statements below
Match the cause and effect

Normal renal perfusion is decreased-GFR is reduced so serum levels of creatinine, BUN, and uric acid rise- while urine output decreases.
Na is retained along with fluid results in increased extracellular volume and edema
Capillary walls of the glomerular endothelial cells allows large protein, primarily albumin, to escape into the urine, decreasing serum albumin
Decreased serum albumin causes decreased plasma colloid osmotic pressure, resulting in further fluid shifts from intravascular into interstitial spaces and edema
Risk of pulmonary edema-risk increases secondary to magnesium sulfate administration as side effect
Vasospasm and injury to endothelial cells can cause fluid shifts from intravascular to extravascular space

Placenta previa
Uterine rupture
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