Coagulation

- Blood clotting factors are higher during pregnancy and 4-6 after child birth, but the
ability for the patient to lyse (break down clots) isnt increased.
- These women are more prone to blood clots, especially is there is a stasis in the
venous system.
- Higher risk of clots with: varicose veins, prior C-section, or delayed ambulation
- Dyspnea and Tachypnea are clear signs of pulmonary embolus.
- Women who deliver via C-section may receive prophylactic anticoagulation therapy
(Heparin) and/or compression devices on the lower extremities to prevent venous
congestion and promote circulation.
Blood Values
- During the early puerperium, it is difficult to determine blood values.
- Massive fluid shifts affect blood levels such as hemoglobin and hematocrit.
- Fluid shifts dilutes blood cells, which lowers hematocrit levels.
- Values may be more accurate 8 weeks postpartum.
- WBC count may rise as high as 12,000-20,000 during this period (Ch. 10 suggests
30,000)
- Increase in WBC is due to inflammation, pain, and stress.
- WBC increase protects mother from infection(s) as tissues heal.
- WBC count returns to normal by 12 days postpartum.
Orthostatic Hypotension
- After child birth, the womans blood pressure falls when she sits or stands. She may
feel dizzy or lightheaded, possibly faint. Bradycardia is standard postpartum.
- After the fourth stage of labor, vital signs are taken every 4 hrs. for the first 24 hrs.
- Temperature may rise to 100.4F in the first 24 hrs.
- High pulse rate after pregnancy often indicates infection or hypovolemia
- Edema (above the waist) is often associated with pregnancy-induced hypertension
- Offer assistance with sitting, toileting, and ambulation, especially for women who
have had a C-section or epidural. Instruct patient to ask for assistance.
Urinary System
Kidney function returns to normal within a month after child birth.
- Pregnancy and IV fluids decrease the tone of the bladder and ureters.
- Womans bladder may fill quickly but empty incompletely
- Hemorrhage (bladder displaces uterus) or UTI (stagnant urine) may occur
GI System
GI System function resumes normal activity shortly after birth when progesterone decreases.
Integumentary System
- Hyperpigmentation of the skin disappears as hormone levels decrease.
- Striae (stretch marks) do not disappear but fade from reddish purple to silver.
Musculoskeletal System
Diastasis Recti longitudinal abdominal muscles (that extend from the chest to the
symphysis pubis) are separated
- Abdominal wall weakness last for 6-8 weeks and may cause constipation
- Hypermobility of joints stabilizes within 6 weeks
- Joints of feet may remain separated
 - Patient may notice increase in shoe size
- Bodys center of gravity returns to normal when the uterus returns to pre-pregnancy
size
- Patient may resume light workouts the first day after vaginal birth. C-section waits
longer.
- Common postpartum workouts include:
- Abdominal tightening
- Head lifts
- Pelvic tilts
- Kegel exercises
Immune System
- Rh-negative mother should receive a dose of RhoGAM within 72 hrs. after giving birth
to an Rh-positive child
- RhoGAM is given to the mother not the infant. IM injection into the deltoid muscle.
Rubella
- Titer of 1:8 or greater indicates immunity to the rubella virus
- Patient who isnt immune to rubella gets vaccine immediately following child
birth
- Women should not get pregnant for 1 month following rubella vaccination
- DO NOT give vaccination to woman sensitive to neomycin
Adaptation of Nursing Care Following C-Section Birth
Terms such as failed induction and failure to progress imply that the woman was no
competent in some way
Uterus
- Check patients fundus of uterus. Make sure it descends properly.
- If patient has a vertical incision, walk fingers towards fundus from side to
abdominal midline
Dressing
- Patient may shower as soon as she is able to ambulate properly.
Urinary Catheter
- Intake and output are measured until IV and catheter are discontinued
- The first 2 of 3 voids are measured
- Measure until woman urinates 150ML
Respiratory Care
- If patient is confined to bed, take deep breaths and turn from side to side every 2 hrs.
- Incentive spirometer may be used to give patient a target for deep breathing
Pain Management
- Most patients change to an oral analgesic the day following C-section surgery
- Mother should receive analgesics right after breastfeeding to minimize drug content
in breast milk
Fathers
- Fathers often experience four phases of adjustment to fatherhood:
1. Having expectations and personal intentions
2. Confronting reality and overcoming frustrations
3. Creating ones own personal father role
4. Reaping rewards of fatherhood
Siblings
- Toddlers: may respond with regression and anger when the mother pays attention to
infant
- Preschool: look at and discuss newborn but may hesitate to touch or hold infant
- Older children: often enjoy helping with care and are very curious about infant
Grieving Parents
- If death of infant was unexpected, the following reactions are common:
- Shock and disbelief
- Anger (often directed at HCP)
- Guilt
- Sadness and depression
- Gradual resolution of the sadness
Postpartum or Nursery Unit Admission
- Nurse may assess temperature, heart rate, and respirations while parents hold the
infant
- Within 1 hr., the nurse does the following:
- Complete physical
- Gestational age assessment
- Administers prophylactics
- Intensive Care Concept is now practiced on all newborns in the immediate
neonatal period until normal transition to extrauterine life. Three phases of this
concept include:
- Phase 1: 0 min. to 30 min. (period of reactivity)
- Tachycardia which continues to lower
- Irregular respirations
- Rales with auscultation
- Infant is alert with frequent Moro (startle reaction)
- Sucking reflex present
- Hypoactive bowel sounds
- Phase 2: 30 min. to 2 hrs. (decreased responsiveness)
- Decreased motor activity
- Rapid respirations (up to 60 per min.)
- Normal HR
- Audible bowel sounds
- Phase 3: 2 hrs. to 8 hrs. (second period of reactivity)
- Abrupt changes in color and muscle tone
- Oral mucus presence (may cause gagging)
- Responds to external stimuli
- Stabilization with suck-swallow coordination (ready for regular
feedings)
Supporting Thermoregulation
- Temperature of a newborn: 96.8F to 97.7F (skin) or 97.7F to 98.6F (axillary)
- Hypothermia may cause the following:
- Hypoglycemia (low blood sugar) infant uses glucose to generate heat
- Respiratory distress higher metabolic rate consumes more oxygen
- Hypoglycemia can cause hypothermia. Hypothermia can cause hypoglycemia.
- Respiratory distress may cause hypoglycemia (using glucose to breathe)
- Heat is lost from the body in the following ways:
- Evaporation sweating
- Conduction direct skin contact with a cold surface (may also add heat)
 - Convection heat is taken away from body by drafts (may also add heat)
- Radiation contact with cold by being near a cold surface (may also add heat)
- DO NOT bathe infant until body temperature is stable at 97.7F to 98.6F
- Temperature is taken 30 min. after bath is given and 1 hr. after transfer to
open crib
Observing Bowel and Urinary Function
- Newborns may not urinate for 24 hrs.
- Infants may not urinate for 48 hrs.
- 70% of term newborns pass meconium within 12 hrs. of birth
- Meconium should be passed before hospital discharge to ensure a patent GI
tract
Evaluating Gestational Age
- A thorough gestational age assessment is done using a scale such as the Ballard form
- Infants who appear pre-term are admitted to nursery more rapidly
- The following characteristics are often assessed:
- Skin
- Pre-term: skin is thin and somewhat transparent
- Post-term: skin is peeling
- Vernix
- Pre-term: covered in cheesy substance
- Term: cheesy substance only in skin creases
- Post-term: green-is vernix indicating meconium was passed
- Hair
- Pre-term: skin heavily covered with fine lanugo hair
- Term: hair only in a few select places
- Ears
- Pre-term: ears spring back slowly when folded
- Term/Post-term: ears spring back quickly when folded
- Breast tissue
- Pre-term: no/minimal breast tissue under nipple
- Term: palpable breast tissue of 5mm or more
- Genitalia
- Pre-term [males]: scrotum is smooth and small
- Term [males]: pendulous and covered with rugae or ridges
- Pre-term [females]: labia majora and labia minora are equal in size
- Term: [females]: labia majora cover the labia minora
- Sole creases
- Pre-term: sole creases only over the anterior 1/3 of foot
- Term: sole creases over the anterior 2/3 of foot
- Post-term: sole creases over the entire foot
Observing for Injuries or Anomalies
- If infant was born vaginally in a breech presentation, the buttocks may be bruised.
Obtaining Vital Signs
- Observation of vital signs begins while parents and infant are bonding.
- Measured at 15 to 30-minute intervals, then hourly, and then every 4 to 8 hrs. with
stability.
- Normal respiratory rate for newborn: 30 to 60 breaths per minute
- Respirations are counted for one full minute.
- Respiratory rate and HR are assessed before disturbing the infant
- Normal HR for newborn: 110 to 160 BPM
 - HR is assessed apically
- Consistently low or high HR may indicate a pathological condition
- Axillary temperature is most commonly used and is safer than a rectal temperature
- Normal BP for newborn: 65/30 mm Hg to 95/60 mm Hg
- When BP is assessed, all four extremities or one arm and one leg are used to
identify substantial pressure differences between the upper and lower
extremities
- Substantial pressure differences can be a sign of coarctation of the aorta
Obtaining Weight and Other Measurements
- Weight is converted to grams for gestational age assessment
- Infant weight measured in kilograms is reviewed at each shift-change
- Three typical measurements are length, head circumference, and chest
circumference
- Head circumference is measured just above the eyebrows (fullest part of
head)
- Chest circumference is measured at the nipple line
Providing Umbilical Cord Care
- The normal umbilical cord has three vessels: two arteries and one vein
- A two-vessel cord is often associated with anomalies (usually GI tract issues)
- Looking at the freshly-cut end of the cord, the two arteries project slightly from the
surface while the one vein looks like a flattened cylinder that doesnt project from the
surface.
- Umbilical cord care is aimed at preventing infection
- Report redness of areas or a moist, foul-smelling umbilical cord
- Baths are given no more often than every other day
Hypoglycemia
- Blood glucose level below 45 mg / dL in term infants indicates hypoglycemia
- If testing indicates hypoglycemia, a venous blood sample is drawn for more
accuracy.
- The heel stick should avoid the center of the heel (bone, nerves, and vessels
near surface)
- Infants are fed immediately after testing to prevent further drops in blood
glucose.
- The brain is dependent on glucose for metabolism. Until regular feedings, stored
glucose is used.
- Infants at risk for hypoglycemia (these infants undergo testing within 1 hr. after
birth):
- pre-term infants and post-term infants
- small for gestational age (SGA) and large for gestational age (LGA) infants
- infants with diabetic mothers
- infants that experience stress because of hypoxia
- Signs of hypoglycemia in the newborn:
- Jittery
- Poor muscle tone
- Sweating
- Respiratory issues
- Low temperature
- Poor suck
- High-pitched cry
- Lethargy
- Seizures
Promoting Bonding and Attachment
- Bonding is the strong emotional tie that forms soon after birth between the parents
and the newborn
- Attachment is the affectionate tie that occurs through time as infant and caregivers
interact
- Partners should touch the infant as soon as possible, reconciling the fantasy of
pregnancy with a child.
 - Parent-infant interactions that dictate a need for additional interventions:
- Indifference to infants signs of hunger or discomfort
- Failure to identify with infants communication
- Avoidance of eye contact with infant
- Discussing the infant in negative terms
Breastfeeding
Review advantages and disadvantages (pg. 222-223)
- Suckling is the giving or taking of nourishment at the breast
Physiology of Lactation
- Two hormones have a major role in the production and expulsion of breast milk:
- Prolactin causes production of the breast milk (from anterior pituitary
gland)
- Oxytocin causes the milk to travel from the alveoli to the nipple; mother
feels a tingling and/or abdominal cramping as uterus contracts during let-
down reflex (from posterior pituitary gland)
Phases of Milk Production
- Milk production changes after birth in three phases:
- Colostrum (late in pregnancy until the first few days after birth)
- Yellow-ish in color
- Rich in protective antibodies, protein, vitamin A/E
- Low in calories in comparison to milk
- Has a laxative effect, which aids in eliminating meconium
- Transitional milk (7 to 10 days after birth)
- Low in immunoglobulins and proteins
- Increased lactose, fat, and calories
- Mature milk (14 days after birth)
- Blue-ish in color
- Thin consistency is normal
- Contains 20 kcal/oz and all nutrients necessary for infant
Assisting the Mother to Breastfeed
- Breastfeeding should not be delayed beyond 6 hrs. after delivery
- The first nursing session has the following benefits:
- Promotes mother-infant bonding
- Maintains infant temperature
- Infant suckling stimulates oxytocin release (contracts uterus and controls
bleeding)
- In the early hours of breastfeeding, nurse should help mother position infant correctly
and help infant obtain an open, gaping mouth in preparation for suckling
- Regardless of breastfeeding position, infants body should be chest-to-chest with
mother, with infants head and neck in alignment
Breastfeeding Techniques
- Manually expressing a few drops of colostrum will make the nipple more erect for
breastfeeding
- Infants tongue position (should be under nipple) can be checked by pulling down on
the lower lip
- After 4 days, the infant generally swallows with every suck at the beginning of
feeding (0.14 ML per suck) and swallows with every two sucks at the end of feeding
(0.01 ML per suck).
- Fluttering sucking motions indicate nonnutritive suckling
Evaluating Intake of the Infant
- By 14 days of age, the breastfed infant should regain its birthweight
- Signs that breastfeeding is successful:
- Breast feels firm before feedings and softer after
- Let-down reflex occurs (tingling when feeding is due)
- Infant nurses at the breast for 10-15 min. per breast 8-10 times per day
- Audible swallow is heard as the infant sucks
- Infant demands feeding and appears relaxed after feeding
- Infant has 6 to 8 wet diapers per day
- Infant passes stool several times per day
Preventing Problems
- Pain, anxiety, and insecurity can inhibit the let-down reflex and are the most common
reason for breastfeeding problems
- May take up to 5 min. for the let-down reflex to occur, leaving infant hungry without
hindmilk
- Breastfed infants usually nurse every 2 to 3 hours during the early weeks because
their stomach capacity is small and breast milk is easily digested
- If the infant has not nursed in 3 hrs., the mother should wake the infant and attempt
to breastfeed
- Infant should nurse at least 15 min. on first breast. After first breast, mother
shouldnt switch back and forth between breasts several times in the same feeding
- Engorgement will occur if milk is not removed from breasts. This may decrease or
stop production.
- Signs of hunger in the newborn:
- Hand-to-mouth movements
- Mouth and tongue movements
- Suckling motions
- Rooting movements
- Clinched fists
- Kicking of legs
- Crying (late sign of hunger)
- In 1991, UNICEF and the WHO launched a baby-friendly hospital initiative aimed at
promoting and supporting breastfeeding
- To be recognized as a baby-friendly hospital, the following criteria must be met:
- Hospital must have written breastfeeding policy and must educate staff
accordingly
- Parents are educated concerning values and techniques of breastfeeding
- Breastfeeding is initiated in delivery room or is maintained if mother and
infant are separated
- Mother and infant are always roomed together. No pacifiers or artificial nipples
are used.
- Formula samples are not distributed at discharge. Referral to support groups is
offered.
Storing and Freezing Breast Milk
- Breast milk should be used within 1 hr. of pumping to avoid the potential for bacterial
contamination
- Any plastic material used for infants should be labeled as BPA-free
- Milk can be stored in refrigerator (at 39F) for 5 to 8 days maximum (in the freezer
section for 2 weeks)
- Milk can be stored in the deep freezer (at -18F) for up to 6 months; may destroy
antimicrobial factors
 - Milk can be thawed in the refrigerator for 24 hrs. DO NOT use a microwave to heat
milk.
Maternal Nutrition
- The pregnant women needs an additional 500 calories per day
- Women who are lactating need a 20-30% increase in vitamins and minerals, twice the
amount of folic acid, and a 40-50% increase in calcium and phosphorus.
- Breastfeeding women should drink one liter of non-caffeinated fluid daily
Weaning
- Gradual weaning is preferred. Abrupt weaning can cause engorgement, mastitis, and
may irritate infant.
- Infant will show disinterest in breastfeeding when a normal diet is introduced around
6 months.
- Tips to wean infant from breastfeeding:
- Eliminate one feeding at a time. Wait several days to eliminate another
feeding.
- Cut out daytime feedings first.
- Eliminate the infants favorite feeding last (often early morning or bedtime
feeding)
- Expect the infant to need comfort nursing, presenting as tired, ill, or
uncomfortable.
Postpartum Self-Care
Mother
- Most HCP want to see postpartum women 2 weeks and 6 weeks after child birth
- At 2 weeks after child birth, healing of the mothers perineum or C-section
incision is assessed.
- At 6 weeks after child birth, general health and recuperation from birth are
assessed.
- Perineal care should be continued until the flow of lochia stops.
- Prescribed prenatal vitamins should generally be taken until after the 6-week
checkup.
- DO NOT use douches and/or tampons until after 6-week checkup
- Ovulation (and pregnancy) can occur before the 6-week checkup
- DO NOT rely on breastfeeding as a form of contraceptive
- Moderate exercise may aid in the return of the uterus to its pre-pregnancy state and
promote well-being
- Hemorrhage, infection, and thrombosis are the most common complications post-
pregnancy.
- Patients should be instructed to report the following after child birth:
- Fever above 100.4F
- Persistent lochia rubra or lochia with a foul odor
- Bright red bleeding
- Prolonged back pains
- Signs of UTI
- Pain, redness, or tenderness of the calf
- Breast tenderness or redness
- Discharge, pain, redness, or separation of any suture line
- Prolonged depression
Infant
- Discharge planning for the infant begins at birth
- Most infants are checked by a HCP at birth and before discharge
- Infant is assessed for jaundice, feeding adequacy, urine/stool output, and
behavior
- If infant is discharged before 72 hrs. of age, AAP recommends a follow-up within 2
days of discharge
- Follow-up within 2 days allows for jaundice detection (bilirubin peaks between
3-5 days of age)
- Newborn should be placed in a rear-facing car seat until 2 years of age
- Limit newborns exposure to crowds before 2 months of age (when antibodies against
infection develop)