Fetal Heart Monitor (distress, interventions) & FHM Strips
• Normal FHR: 110-160
• Accelerations:
o Temporary increase
o Reassuring no
... [Show More] interventions
• Early deceleration: mirror mom’s contractions
o Cause: compression of baby’s head on pelvis/soft tissue
o Normal – no interventions, expected finding
• Late deceleration: responds after contraction
o Cause: uteroplacental insufficiency
o Non-reassuring needs intervention
o Nursing interventions: side-lying position, IV fluids, discontinue oxytocin, administer O2, palpate uterus for tachysystole (more frequent intense contractions), notify provider
• Variable deceleration: not uniform look for Vs
o Cause: cord compression
o Requires intervention
o Nursing interventions: knee-chest position or side-side repositioning, discontinue oxytocin, administer O2, notify provider
• REMEMBER VEAL CHOP MINE
V – variable C – cord compression M – move side left
E – early decels H – head compression I – identify labor progression
A – acceleration O – OK N – no intervention
L – late decels P – placental insufficiency E – execute immediately STOP = stop Pitocin,
turn patient on side, O2 via face mask, plain IV fluid increased
• Fetal bradycardia: FHR drops below 110 for at least 10 minutes
o Causes: uteroplacental insufficiency, umbilical cord prolapses, maternal hypotension, anesthetic meds mom received
o Interventions: stop oxytocin, left side position, O2, notify provider
• Fetal tachycardia: FHR increases above 160 for over 10 minutes
o Causes: infection, cocaine use, dehydration
o Interventions: antipyretics, oxygen, IV fluid bolus
• The contractions:
o Increment: beginning, building of pressure
o Acme: most intense part of the contraction
o Decrement: diminishing of the contraction
o Rest: period of time between contractions BUBBLE HER
• Breasts:
o Inspect for size, contour, asymmetry, engorgement, or erythema
o Check the nipples for cracks, redness, fissures, or bleeding
▪ Note if they are erect, flat, or inverted
• Uterus:
o Assess the fundus to determine the degree of uterine involution
▪ Have the woman empty her bladder first before assessing the fundus
o Fundus should be midline and should not feel boggy or relaxed
o 1-2 hours after birth, the fundus is between the umbilicus & the symphysis pubis
o 6-12 hours birth, the fundus is usually at the level of the umbilicus
o The fundus progresses downward at a rate of 1 fingerbreadth or 1 cm per day after childbirth
o On the first postpartum day, the top of the fundus is located 1 cm below the umbilicus and is recorded as U/1
o If the fundus is NOT firm, then gently massage the uterus using a circular motion until it becomes firm
• Bladder:
o Assess the bladder for distention & adequate emptying after efforts to void
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o If the bladder is full, lochia drainage will be more than normal b/c the uterus cannot contract to suppress the bleeding
o Note the location & condition of the fundus – a full bladder tends to displace the uterus up & to the right
o Be alert for signs of infection, including infrequent or insufficient voiding (less
than 200 mL), discomfort, burning, urgency, or foul-smelling urine
• Bowels:
o Spontaneous bowel movements may NOT occur for 2-3 days after giving birth b/c of a decrease in muscle tone in the intestines during labor
o Normal patterns of bowel elimination usually return within 8-14 days after birth
o Inspect the woman’s abdomen for distention, auscultate for bowel sounds in all 4 quadrants, & palpate for tenderness
o Ask the woman if she has had a bowel movement or has passed gas since giving birth
• Lochia:
o Assess the amount, color, and odor of lochia
▪ Ask about the # of perineal pads used in the past 2-4 hours & how much drainage was on each pad
▪ Color:
• Rubra/red: 1-3 days
• Serosa/pink: 3-10 days
• Alba/white: 10-14 days
o The amount of lochia on perineal pad is described as follows:
▪ Scant: 1-2-inch lochia stain or approx. a 10 mL loss
▪ Light or small: an approx. 4-inch stain or a 10-25 mL loss
▪ Moderate: a 4-6-inch stain w/ an estimated loss of 25-50 mL
▪ Large or heavy: a pad is saturated within 1 hour after changing it
o Report any abnormal findings, such as heavy, bright-red lochia w/ large tissue fragments or a foul odor to the physician
o Teach patient about frequent changing of perineal pads, continuous use of the peribottle, and proper handwashing before & after changing the pad
• Episiotomy/Perineum:
o Inspect the episiotomy for irritation, ecchymosis, tenderness, or hematomas
o Assess for hemorrhoids & their condition
o Redness, swelling, increasing discomfort, or purulent drainage may indicate infection
o Ice can be applied to relieve discomfort & reduce edema
o Sitz baths can also promote comfort & perineal healing
• Homan’s Sign: do NOT do, BUT still assess
o Assess legs for DVT, unilateral swelling, erythema, & warmth
▪ Encourage ambulation
o Cardiovascular changes after delivery
▪ Blood loss:
• Vaginal – 500 mL
• C-section – 1,000 mL
▪ Coagulation factors increased for 2-3 weeks after birth, which increases risk for blood cloth
▪ Elevated WBC for the first week
▪ Check if calves & legs are soft & NOT painful – has she been up since delivery
• Emotion: emotional status – happy, tearful, sad, relieved; allow the patient time to rest
o Be alert of mood swings, irritability, or crying episodes, which could show postpartum depression or psychosis
o Remember cultural considerations
• Rhogam:
o Administered 72 hours after birth to Rh negative moms who gave birth to Rh positive babies to prevent the formation of antibodies to protect future babies
o Also, given at 28 weeks
Postpartum Assessment (lochia, fundus position, etc)
• Lochia:
o Red/rubra – 1-3 days
o Pink/serosa – 3-10 days
o White/alba – 10-14 days
• Assessments:
o Every 15 min. during the 1st hour
o Every 30 min. during the 2nd hour
o Every 4 hours during the first 24 hours
o Every 8 hours after the first 24 hours
• Vital signs:
o Temp.:
▪ May rise up to 38 °C (100.4 °F) – during the first 24 hours in some women due to dehydration
▪ If temp. is above 38 °C (100.4 °F) at any time or an abnormal temp. after the first 24 hours may indicate infection & MUST be reported
o Pulse rate:
▪ Bradycardia may be noted due to changes in blood volume & cardiac output after delivery
▪ Pulse usually stabilizes to pre-pregnancy levels within 10 days
▪ Tachycardia in the postpartum woman can suggest anxiety, excitement,
fatigue, pain, excessive blood loss, infection, or underlying cardiac problems
o Respirations:
▪ RR should be within normal range (16-20 breaths/min)
▪ Lungs should be clear on auscultation
o Blood pressure:
▪ Compare BP w/ client’s usual range
▪ Elevations in BP from baseline may suggest pregnancy-induced hypertension; decreases may suggest dehydration or excessive blood loss
▪ Be alert for orthostatic hypotension
o Pain:
▪ Assess patient’s pain on a scale of 0-10
▪ Goal of pain management: have client’s pain on a scale of 0-2 at all times
▪ If client complains of severe perineal pain – inspect & palpate for hematoma
Maternal Adjustment
• Psychological adaptations:
o Taking in:
▪ Occurs immediately after birth when mother needs sleep, depends on others to meet her needs, & relieves the event surrounding the birth process
▪ Occurs during the first 24-48 hours after birth, mother assume a passive role in meeting her own basic needs for food, fluid, & rest (dependent on nurse to make decisions for them)
▪ Spend time telling others about labor experience
▪ Touches & explores infants
o Taking hold:
▪ The second phase is characterized by dependent & independent maternal behavior
▪ Starts 2-3 day postpartum, & may last several weeks
▪ Mother start to regain control over body functions & thought of the present (concerned about her health, infant condition, & ability to care for
infant)
▪ Demonstrate increased autonomy & independence by expressing strong interest
o Letting go:
▪ The third phase occur when the woman reestablishes relationships w/ other people
▪ Begins to adapt to parenthood through her new roles
▪ Becomes focus on moving forward by assuming the parental role by separating herself from the symbolic relationship she & her newborn had
during pregnancy
▪ Establishes a lifestyle that includes the infant
o Roles attainment:
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▪ Role attainment, a process mother forms an emotional relationship w/ infant over time
▪ Commitment, mother attachment to unborn baby, & preparation for delivery & motherhood during pregnancy
▪ Acquaintance/attachment to the infant, learning to care for the infant, & physical restoration during first 2-6 weeks following birth
▪ Moving toward a new normal
▪ Achievement of a maternal identity through redefining self to incorporate motherhood (around 4 months). During this time mother feels self-
confident & competent in her mothering roles & expresses love for & pleasure interacting w/ her infant
• Mood disorders:
o 3 distinct entities in ascending order of severity:
▪ baby blues:
• characterized by mild depressive symptoms – mood swings, anger, anxiety, irritability, tearfulness (often for no reason)
• the “blues” typically peak on postpartum 4th & 5th day, may last hours to days
o usually resolves by day 10 w/o therapy
• nursing management:
o encourage mother to express her feelings to ease
o be patient & understanding to her & family
o suggest getting outside help w/ housework & infant care
o provide telephone numbers that she can call when she’s down
o reassure patient that feelings are normal & temporal
▪ postpartum depression: major depressive disorder that occurs in women after childbirth
• usually occurs if symptoms of “baby blues” lasts longer than 6 weeks & seems to get worse
• s/s: more severe than “baby blues”, requires treatment
o feeling restless, worthless, guilty, hopeless, moody, sad, & overwhelmed
o also, at risk of hurting self or infant
• treatment:
o antidepressant, antianxiety, & psychotherapy
o marriage counseling, may be required if marital problems are contributing to symptoms
▪ postpartum psychosis: severe depressive disorder
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