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1ST SEMESTER (FINAL)| A.Y. 2023-2024 ___________________________________________ PPT-BASED

NURSING CARE OF MOTHER AND THE FETUS DURING SEROSA
POSTPARTUM PERIOD • pinkish brown discharge, odorless
• 4-10 days
POSTPARTUM PERIOD • mostly serum (mucus), some blood, invading
− Starts immediately after delivery – 6 weeks following leukoytes
delivery (Puerperium) ALBA
− Occurs from delivery of the placenta for up to 6 weeks • white discharge , odorless
after delivery (when all body system are returned to, • 10 – 14 days (may last 6 weeks)
or nearly to their pre-pregnant state. • largely mucus, leukocyte count is high
POSTPARTUM ASSESSMENT B. Cervix” flabby immediately after delivery,
• Physiological Maternal Changes: closes slowly
A. Involution (Uterus) − Admits one fingertip by the end of
− the rapid decrease in the size of one week after delivery
the uterus as it returns to the non- − Shapes of external os changed by
pregnant state delivery from round to slit like
− After delivery, it can be palpated opening
below the umbilicus, and regresses C. Vagina/Perineum
approximately 1cm (one − Edematous after delivery
fingerbreadth) per day until by the − Inspect episiotomy for normal
end of 2nd week postpartum (10th healing
day cannot be palpated through − Observe REEDA (redness, edema,
abdominal wall-behind the ecchymosis, discharge
symphysis pubis) approximation), and hematoma
− May have small lacerations
− Episiotomy heals usually 2-3
weeks, unless laceration from
vagina and rectum is present
− Development of hemorrhoids
D. Breast
• Nonlactating:
− Prolactin level falls rapidly
− May still secrete colostrum for 2-3
days
− Engorgement of breasts tissue
resulting from temporary
• Flaccid fundus = UTERINE ATONY congestion of veins and circulation
− Intervention: massage until firm occurs on 3rd day, lasts 24-36
• Tender fundus = INFECTION hours, usually resolves
spontaneously
• Fundus should be firm, in midline and slightly below
umbilicus immediately after delivery − Client should wear tight bra to
compress ducts and use cold
• The woman should empty bladder during postpartal
applications to reduce swelling
assessment
LOCHIA • Lactating:
• Discharge from the uterus that consists of blood from − High level of prolactin immediately
the vessels of the placental site and debris from the after delivery of placenta by
decidua frequent contact with nursing baby.
• Assessment: − Initial secretion of colostrum, with
increasing amount of true breast
− Assess color, amount, clots, odor
milk appearing between 48-96
• Amount of Lochia:
hours
− Scant
− Milk “let-down” reflex caused by
− Light Heavy oxytocin from posterior pituitary
− Excessive gland release by sucking
E. Ovarian function and menstruation
− First cycle is usually anovulatory.
− If lactating, menses less
predictable, may resume in 12-24
weeks
− If not lactating, menses may
resume in 6-10 weeks (average of
4-6 weeks)
RUBRA
CARDIOVASCULAR/CIRCULATORY SYSTEM
• bright red “fleshy” (with clots)
− Blood loss: NVD 300cc-500cc
1-3 days
contains: blood, fragments of decidua, mucus − Blood loss: CS 500-1000cc
 − In 4-6 weeks, the HCT usually returns to • Letting-Go
prepregnancy value − Still focuses on the family as a unit and
− Increased clotting factors remain for several weeks show pattern of lifestyle which includes new
causing risk problem for thrombi baby
URINARY TRACT − Re-establishment of father0mother bond
− As a result of urethral edema, the postpartum woman − Mother may still feel tired and overwhelmed
may have difficulty voiding in immediate after with responsibility, with conflicting demands
delivery on time and her energy
− Mark diuresis begins within 12 hours of delivery; − Mother may feel deep loss over separation of
increase volume of urinary output and perspiration the baby from part of the body and may
loss grieve over the loss
− Lactosuria may be seen − Woman redefines new role “Bursting out”
− Slight proteinuria may occur during 1-2 days of − Assumes independent role and responsible
involution Elimination patterns:
GASTROINTESTINAL SYSTEM − Voiding, flatus, bowels
− After delivery, the woman is usually hungry; good Legs:
appetite − Pain, warmth, tenderness indicating thrombosis
− Due to lack of muscle tone in abdomen and intestinal Assess for thrombophlebitis
tract and perineal soreness, may still experience − (+) Homan’s sign: presence of pain in the calf of the
constipation woman while her ankle is in
SKIN dorsiflexed position
− To reestablish good muscle tone, may need 6 weeks
− Disappearance (silvery appearance) of stretch
marks gradually
VITAL SIGNS CHANGES
1. Temperature:
− may be elevated during the 1st 24 hours
because of dehydration (38 ⁰C)
− Temperature over 100.4 degree Fahrenheit
(37.8 degree Celsius) after 24 hours and
>48 hours indicates infection
2. Pulse: POSTPARTUM DISCOMFORTS
− Bradycardia is common during the 1st week 1. Afterbirth pains : occur as a result of contractions of
with a range of 50-70 beats/min the uterus
− > 100 bpm = excessive blood loss or 2. Perineal discomfort:
infection a. Apply ice packs to the perineum during
3. BP remains unchanged the 1st 24 hours (as ordered) to reduce
− if decreased indicates bleeding swelling
(hypovolemia) b. After the 1st 24 hours, apply warmth by sitz
− If elevated (140/90mmHg) indicates PIH bath (as ordered) to relieve hemorrhoidal
4. Respirations - rarely changed discomforts
c. Use heat lamp treatment (20 minutes, 3X a
− (if increased = pulmonary embolism
day, and 10-20 inches from perineum)
− uterine atony
Episiotomy
− hemorrhage
− Perineal care after each voiding
RUBIN’S POSTPARTUM PHASES OF REGENERATION
− Use analgesic spray as prescribed
Emotional Adaptation to Pregnancy
• Taking-In- lasts for 1-3 days − Analgesics as prescribed if comfort measures are
unsuccessful
− Mother focuses on her own primary needs
(sleep and food are important) − Promote perineal exercises to relieve episiotomy
discomfort (Kegel’s exercise: contracting and
− Passive, with “sleep hunger”, cannot
relaxing muscles of the perineum 5-10 times, as if
communicate
trying to stop voiding)
− Time of reflection
Perineal lacerations
− Dependent 1. Administer perineal care and use analgesic spray and
• Taking-Hold- 3 – 10 days (last for 1 week) analgesics for comfort
− Dependent/independent 2. Rectal suppositories and enemas may be
− wants to be in control, 3rd day may re-assert contraindicated (avoid injury on the sutures)
herself, strong desire to be independent, F. Breast discomfort from engorgement
more active and participative − Assist with breastfeeding as needed
− Has strong interest to take care of baby G. Constipation
− Can identify own needs − Early ambulation
− Requires reassurance that the mother can − Adequate fluid intake Adequate
perform tasks of motherhood roughage (fiber) in diet
− Some emotional lability, may cry for no H. Postpartum blues
reason ** Measure voiding for sufficiency, observe I & O for the first 24
hours
Nutritional counselling: • Abdominal Wall/ skin
− Breastfeeding 200 – 500 cal/day a. may need 6 weeks to reestablish good
− increase fluid and continue prenatal vitamins and muscle tone . This time sexual intercourse
minerals can be resumed.
b. Stretch mark gradually disappears or fade to
NURSING CARE DURING POSTPARTUM silvery appearance
• Puerperium – refers to the postpartum period or the 6 • Cardiovascular System / Circulatory System
week period after birth. a. Hematocrit usually returns to prepregnant
• Involution – begins with the delivery of the placenta value within 4-6 weeks
and ends when all the body systems are returned to, b. WBC count increases
or nearly to their prepregnant state. Ovulatory or c. Increased clotting factors remain for several
menstrual cycle may or may not return. weeks leaving woman at risk for problems
SPECIFIC BODY SYSTEM CHANGES with thrombi.
REPRODUCTIVE System • Urinary System
1. Uterus – rapid reversal in size a. May have difficulty in voiding in immediate
− After delivery uterus is below the umbilicus , postpartum periods as a result of urethral
the uterus regresses approximately 1 edema
fingerbreadth ( 1 cm ) per day until the end b. Diuresis begins within 12 hours of delivery ,
of the second week postpartum it is in pelvic increase volume of urinary output as well as
cavity and no longer palpable. perspiration
Endometrial surface sloughed off as lochia, in three stages c. Lactosuria may be seen in nursing mother
• Lochia rubra – dark red color, days 1-3 after delivery d. Many woman will show slight proteinuria
, consist of blood and cellular debris from decidua during 1-2 days of involution.
• Lochia serosa – pinkish brown , days 3-10 mostly • Gastrointestinal System
serum , some blood, tissue debris a. mother is usually hungry after delivery, good
• Lochia alba – yellowish white, days 10-14, most appetite is expected
leukocytes with decidua, epithelial cells , mucus b. may experience constipation from lack of
2. Cervix – flabby, immediately after delivery, closes muscle tone in abdomen and intestinal tract
slowly and perineal soreness
a. admits one fingertip by the end of one week • Vital Signs Changes
after delivery a. Temperature – slightly increased during the
b. Shapes of external os changed by delivery first 24 hours after birth ( dehydration )
from round to slit like opening b. Blood Pressure – decreased indicates
3. Vaginal Perineum bleeding, if elevated to 140/90 mmHg.
a. edematous after delivery .Inspect Indicates pregnancy induced hypertension.
episiotomy daily for normal healing , c. Pulse – slightly slower than normal due to
observe for redness, edema , ecchymosis increased stroke volume brought about by
and hematoma increasing blood volume returning to the
b. may have small lacerations heart.
c. smooth walled for 3-4 weeks , then rugae POSTPARTAL PSYCHOSOCIAL CHANGES
reappear • Adaptation to Parenthood- Attachment Skills
4. Ovulation / Menstruation A. Bonding-development of a caring
a. first cycle is usually anovulatory, if not relationship with the baby.
lactating , menses may resume in 6-10 − Behaviors includes:
weeks, average of 4-6 weeks 1. Claiming – how baby looks or acts
b. If lactating menses less predictable , may 2. Identification – unique nature, giving name
resume in 12-24 weeks 3. Attachment is facilitated by positive
5. Breasts feedback between baby and caregiver
• Non Lactating woman B. Sensual Response
a. prolactin levels falls rapidly 1. Touch
b. may still secrete colostrum for 2-3 days 2. Eye to eye contact
c. engorgement of breast – occurs on 3rd day , 3. Voice
lasts 24-36 hours 4. Odor
d. client wear tight bra to compress ducts and 5. Entertainment
use cold applications to reduce swelling 6. Biorhythm- baby respond to mothers
• Lactating woman heartbeat
a. high level of prolactin immediately after • Maternal Adjustment / Maternal Psychologic
delivery of placenta by frequent contact with Adaptation
nursing baby 3 Phases
b. Initial secretion of colostrum, increasing 1. Dependent “Taking In “
amount of true breast milk appearing − 1-2 after delivery
between 48-96 hours − Mother is passive, dependent
c. Milk let down reflex caused by oxytocin from − Mother may need help with daily activities,
posterior pituitary gland released by sucking. as well as child care
d. Successful lactation results from complex − Food / sleep is important
interaction of infant sucking reflexes and − Mother is passive and can’t communicate
maternal production and let down of milk.
 2. Dependent / Independent “Taking Hold “
− 3- 7 days after delivery
− By 3rd day mother begins to reassert herself
− Identifies own needs, and baby’s needs
− Some emotional lability, may cry for no
reason
− Mother is active , assume independent role
and participative
3. Independent “Letting Go “
− Usually evident by 7th day or sixth week
− Show pattern of lifestyle that includes the
baby Amniotomy- artificial rupturing of membrane during labor.
− Re-establishment of father-mother bond − To allow the fetal head to contact directly to the cervix
seen in this period more directly, increases the efficiency of contractions
− Mother may still feel tired and overwhelmed and therefore speeds labor.
by her responsibility and conflicting demands Procedure:
on her time and energies. − Woman is in dorsal recumbent position then an
− Mother redefines new role, assumes amnionhook (a thin crochet- like instrument or
independent role and responsible hemostat) is passed vaginally to and membrane is
POSTPARTAL ASSESSMENT torn to escape the amniotic fluid.
A. Physical Assessment Disadvantage – possible for cord prolapse. Monitor
− Vital Signs – individual protocol until FHB after the procedure
stable, then at least every 8 hours EPISIOTOMY- surgical incision of the perineum to prevent
− Temperature of 100.4 F or 37.8 C tearing of the perineum
after 24 hours , lasting more than − Release pressure on the head with birth and possibly
48 hours , indicative of infection shorten the last portion of the second stage of labor.
B. Fundus − Incision is made by a blunt-tipped scissor
− after delivery of the placenta , − Midline episiotomy –incision is midline, less blood loss
fundus is midway between and heals easily
umbilicus and symphysis pubis − Mediolateral episiotomy- incision in the midline then
− should be firm, in midline , slightly directed laterally away from the rectum, thus creating
below umbilicus immediately after less danger of rectal mucosal tear.
birth Procedures for High –Risk Pregnancies
− After 6-12 hours should rise to level • Internal Electronic Monitoring – most precise method
of umbilicus , 1 cm above of assessing FHR and uterine contractions. A
− After postpartum day ( 24 hours ) wireless telemetry is managed by a pressure sensing
fundus descends 1 fingerbreadth or catheter passed through the vagina after the
1 cm membrane has ruptured and cervix dilated at least 3
cm. It is then passed into the uterine cavity alongside
− At 10 days , fundus cannot be
the fetus. The end of the catheter is attached to a
palpated because it is behind the
pressure recorder. As the uterus contracts puts
symphysis pubis
pressure to the catheters and thus recorded.
− Should regress 1 cm / day
(Frequency, duration, baseline strength, and peak
thereafter until the end of 2nd week
strength contraction, evaluate the senses of uterine
− Assessment should be done with tone to baseline strength between contractions. (
client’s bladder empty monitor placental filling )
Contractions:
SURGICAL INTERVENTION FOR BIRTH • Latent phase –baseline level is less than 5mmHg
• Active phase –about 12 mmHg
NURSING PROCESS OVERVIEW • During the 2nd stage of labor as high as 20 mmHg
• Baseline reading that do not return to 20 mmHg or
less indicates hypertonia and can compromise fetal
well-being.
• FHR is recorded with fetal scalp electrode.
CESAREAN BIRTH
• Indications or alleviate problems of birth.
1. CPD
2. breech or multiple fetus birth
3. failure to progress in labor
4. transverse presentation
5. reduces the transfer of herpes type 2 from
mother to newborn
• Scheduled or elective cesarean birth –planned there
is thorough preparation throughout the antepartal
period.

EMERGENT CESAREAN BIRTH-DONE FOR A REASON

THAT ARISE SUDDENLY IN LABOR.
 • Such as: • Fetal bradycardia – FHR lower than 110 beats per
1. placenta previa minute
2. premature separation of placenta • Fetal Tachycardia – FHR is faster than 160 beats per
3. fetal distress minute for a 10 minute period.
4. failure to progress labor PERIODIC CHANGES OR FLUCTUATIONS IN FHR OCCUR
• Risk for emergent CS IN RESPONSE TO CONTRACTIONS AND FETAL
1. may not be prime candidate for anesthesia MOVEMENT.
or psychologically unprepared • this can be describe as accelerations or
2. may have fluid and electrolyte balance decelerations.
3. physically & emotionally exhausted from • Periodic changes are short term changes in rate order
long labor than baseline: last from few seconds to 1 or 2
Effects of surgery on a woman minutes.
1. stress response- stress increases release of • Accelerations – nonperiodic accelerations are
epinephrine and norepinephrine that results to temporary normal increases in FHR caused by:
increase heart rate, elevates blood glucose, broncho − Fetal movements
dilation, high BP due to peripheral vasoconstriction − Change in maternal position
that forces blood circulation to ventral part and − Administration of analgesic
minimize blood supply to lower extremities • an acceleration –visually apparent abrupt increase (
2. interference with body defenses- onset to peak in less than 30 seconds ) in FHR
3. interference with circulatory system • at 32 weeks and beyond – acceleration a peak of 15
4. interference with body organ function beats per minute or more above baseline with
5. interference with self-image or self esteem duration of 15 seconds or more but less than 2
Nursing care for woman anticipating a cesarean birth. minutes from onset to return
A. Preoperative interview • before 32 weeks of gestation -acceleration a peak of
B. Operative risk for a woman 10 beats per minute or more above baseline with
1. poor nutritional status duration of 10 seconds or more but less than 2
2. age variations minutes from onset to return
3. altered general health • > prolonged acceleration last 2 minutes or more but
4. fluid and electrolyte imbalance less than 10 minutes in duration
5. fear • > if an acceleration last 10 minutes or longer , it is
baseline or a new baseline is established
FETAL HEART RATE PARAMETERS • Decelerations – periodic decreases in FHR resulting
• Assessing and interpreting FHR patterns involves from pressure on the fetal head during contractions as
evaluating three parameters. parasympathetic stimulation in response to vagal
1. the baseline rate nerve compression brings about a slowing FHR.
2. variabilities in the baseline rate • Early deceleration – normally occur late in labor, when
3. Periodic changes in the rate ( acceleration the head has descended fairly low. The head
and deceleration ) compression causing the waveform change could be
• Baseline FHR – analyzing the pace of FHB recorded the result of CPD
in a minimum of 2 minutes obtained between • Late Deceleration – occur after the beginning, peak
contractions. Normal rate is 110 to 160 beats per and ending of the contraction respectively. It occurs
minute. due to uteroplacental insufficiency or decreased blood
• Variability – FHB variability or the difference between flow through the intervillous spaces of the uterus
the highest and lowest heart rates shown on a strip, is during uterine contractions.
one of the most reliable indicators of fetal well-being. • This pattern may occur with marked hypertonia or
Variability is reflected on a FHR tracing as a slight increased uterine tone
irregularity or jitter to the wave. Degree of baseline • Immediately change the position of the mother from
variability increases 5 to 15 beats per minute when supine to lateral – to relieve pressure on the vena
fetus moves, slows when fetus sleeps. cava and supply blood to the uterus and fetus.
• > if no variability is present – indicates the natural • Prolonged Deceleration – are decelerations that are
pacemaker activity of the fetal heart ( effect of decrease from the FHR baseline of 15 beats per
sympathetic and parasympathetic nervous system ) minute or more and last longer than 2-3 minutes but
may be affected. less than 10 minutes. Generally signifies cord
• > narcotics or barbiturates administered during labor , compression or maternal hypotension. If a
but possibility of fetal hypoxia and acidosis –may be deceleration lasts longer than 10 minutes is
considered and investigated considered a baseline change and must be reported
• > very immature fetuses show diminished baseline and documented.
variability because of reduced nervous system • Variable Deceleration –refers to deceleration that
response to stimulation and immature cardiac mode occur at unpredictable times in relation to
function. contractions. May indicate cord compression that can
Variability should be recorded as: affect fetal well-being. Cord compression may occur
• > absent – no amplitude range is detectable because of
• > Minimal – amplitude range is detectable but is 5 − prolapsed cord
beats per minute or fewer − After rupture of membrane
• >Moderate ( Normal )-amplitude range is 6 to 25 − >oligohydramnios
beats per minute − Change position of the mother from supine to
• > Marked – amplitude is greater than 25 beats per lateral position, knee-chest position to relieve
minute. pressure on the cord.