NSG210 Durham Ch. 12: Postpartum Physiological Assessments and Nursing Care

Source: Durham & Chapman, Maternal-Newborn Nursing 4e, Chapter 12, pp. 399-428 (textbooks/DURHAM_OB_CH12.pdf, also in textbooks/exam03/). Week 10 reading (OB Lectures 6-7, October 28); on Exam 3. Lecture slides: raw/nsg210_wk10_OBLecture4.md (postpartum section, slides 1-24). Complications (hemorrhage, infection, VTE, mood disorders) are in nsg210-durham-ch14-high-risk-postpartum; psychological adaptation is in nsg210-durham-ch13-transition-to-parenthood.

Learning Outcomes

1. Describe the physiological changes of the postpartum period.
2. Identify critical elements of postpartum assessment and nursing care.
3. Discuss safe and effective postpartum nursing care.
4. Outline the critical elements of discharge teaching.

Nursing diagnoses: pain (uterine involution, perineal trauma, engorgement); risk for infection (perineum, mastitis); risk for fluid volume deficit from uterine atony; risk for impaired urinary elimination; risk for constipation; knowledge deficit about postbirth health promotion.

Expected outcomes: firm fundus with scant to moderate lochia; spontaneous void within 2 to 4 hours of birth; at least 10 glasses (80 oz) of fluid a day with a high-fiber diet; verbalizes warning signs and follow-up plan.

I. Overview

• Postpartum period: the 6 weeks after childbirth; the “fourth trimester”
• Maternal mortality: death from pregnancy complications up to 1 year postpartum. US rate rose from 16.9 (2016) to 17.3 (2017) per 100,000 live births, more than double the 1987 rate (7.2)
• Healthy People 2030 targets (Table 12-1): reduce maternal deaths to 15.7 per 100,000; increase exclusive breastfeeding through 6 months; increase postpartum depression screening; reduce unintended pregnancies and pregnancies within 18 months of a prior birth
• Screen for perinatal mood and anxiety disorders with a standardized tool such as the Edinburgh Postnatal Depression Scale (EPDS); screening alone does not improve outcomes without follow-up systems

Box 12-1, postpartum assessment overview: vital signs, pain, breath and heart sounds; labs (CBC, rubella, Rh status); vaccines (Tdap, influenza, pneumococcal, COVID-19); breasts; uterus; bladder; bowel; lochia; episiotomy, lacerations, perineum, hemorrhoids; lower extremities; emotions, bonding, fatigue, psychosocial factors.

II. Reproductive System

A. Uterus and involution

• Involution: return of the uterus to near prepregnant size, shape and location; takes 6 to 8 weeks. Happens through contractions, muscle atrophy and smaller uterine cells
• The contracted myometrium compresses open vessels at the placental site and limits blood loss
• Afterpains: cramping from contractions; more common in multiparas and with breastfeeding (suckling releases oxytocin); worse with each additional birth; usually ease after day 3. Primiparas usually have little cramping because the uterus stays contracted
• Afterpain comfort: void often (a full bladder worsens cramping), warm blanket on the abdomen, relaxation, ibuprofen or acetaminophen

Assessment frequency for fundus, VS, RR and temperature (same schedule for all):

• Every 15 minutes for the first hour
• Every 30 minutes for the second hour
• Every 4 hours for the next 22 hours
• Every shift after 24 hours, and more often if findings are abnormal

Hemorrhage timing:

• Greatest risk is in the first hour after birth
• Primary (early) PPH: within 24 hours
• Secondary (late) PPH: 24 hours to 12 weeks, most often days 7 to 14

Fundal assessment technique:

• Have her void first (a full bladder displaces the uterus and causes atony)
• Explain, give privacy, lay her flat and supine, remove the pad so lochia is checked at the same time
• Support the lower uterine segment with one hand just above the symphysis pubis (prevents uterine inversion)
• Palpate the fundus with the other hand; note position, tone and location
• Measure in fingerbreadths from the umbilicus: 1 fingerbreadth = 1 cm

Expected fundal findings:

• Immediately after birth: midway between umbilicus and symphysis, firm, midline; rises to the umbilicus within a few hours
• Within 12 hours: at the umbilicus or 1 cm above, firm, midline
• 24 hours: 1 cm below the umbilicus
• Descends 1 cm per day; not palpable by day 14

Deviations:

• Uterus deviated to the side (usually right), soft or above the umbilicus: full bladder. Immediate action is to help her void, then reassess; catheterize if she cannot void
• Subinvolution: uterus fails to descend as expected. Causes: retained placental fragments, infection, overdistended uterus (large baby). Leads to prolonged or excessive bleeding

Critical Component, uterine atony (boggy uterus):

• Most common cause of postpartum hemorrhage
• Boggy uterus means it is not contracted and bleeding risk is high
• Immediate action: massage the fundus with the palm in a circular motion until firm; reevaluate in 5 to 10 minutes
• No response to massage: give oxytocin per standing order and notify the provider
• Continued heavy bleeding with a FIRM fundus suggests a genital tract laceration or vulvar or vaginal hematoma

B. Endometrium and lochia

• Placental site heals by exfoliation (necrotic tissue sloughs and endometrium regenerates), which prevents scarring
• Lochia: discharge of RBCs, decidual tissue, epithelial cells and bacteria; a medium for bacterial growth
• Primary complication: metritis (endometrial infection; see Ch. 14)

Table 12-2, stages of lochia:

Amount (Fig. 12-3):

• Scant: under 1 inch on the pad (blood only on tissue when wiped, or a 1 to 2 inch stain)
• Light: under 4 inches
• Moderate: under 6 inches (text also says under 5 inches)
• Heavy: pad saturated within 1 hour
• Excessively heavy: pad saturated within 15 minutes

Clots and blood loss:

• Clots form when lochia pools in the lower uterine segment
• Note small clots in the chart; weigh any clot the size of an egg or larger and report it (large clots interfere with involution)
• 1 g of weight = 1 mL of blood loss
• Examine clots for tissue: retained placenta causes subinvolution and bleeding

Lochia teaching:

• Flow increases on rising in the morning or after sitting (pooling) and with heavy activity
• Report an increase in flow, a return to bright red after rubra ends, or a foul odor
• Change pads often, wash hands before and after, use a peri-bottle
• Teach her to check and massage her own fundus; secondary hemorrhage often happens after discharge. Causes: subinvolution, infection, retained tissue, von Willebrand disease

C. Clinical judgment: excessive bleeding

• PPH is the leading cause of US maternal mortality (10.7% of deaths, 2014-2017)
• Visual estimation (EBL) is inaccurate and delays treatment; use quantified blood loss (QBL) by weighing soaked items and clots (1 g = 1 mL). Scales and a PPH cart with algorithms belong in every unit
• Immediate actions: assess fundal position, tone and location; massage if boggy; if boggy and displaced, have her void (bladder scanner if available) and reassess; weigh all pads; notify the team; follow the hemorrhage staging algorithm if atony continues

Box 12-2, Maternal Early Warning Criteria (urgent bedside evaluation if a value persists, recurs, or comes with other abnormal values):

• Systolic BP under 90 or over 160
• Diastolic BP over 100
• Heart rate under 50 or over 120
• Respiratory rate under 10 or over 30
• SpO2 under 95% on room air
• Oliguria under 35 mL/hr for 2 hours or more
• Agitation, confusion or unresponsiveness
• Preeclampsia with a nonremitting headache or shortness of breath

While waiting for the clinician: secure free-flowing IV access, increase VS frequency, give oxygen, have a catheter, uterotonics and lab supplies at the bedside, consider a rapid response.

D. Vagina and perineum

Laceration degrees:

• First: vaginal mucosa and perineal skin
• Second: adds fascia of the perineal body
• Third: adds the rectal sphincter
• Fourth: extends through the rectal mucosa and lumen
• Midline episiotomy heals faster with less pain; mediolateral is cut at 45 degrees

Notes:

• Third- and fourth-degree lacerations, episiotomy and hemorrhoids may need a stool softener or laxative
• Primary complication is infection at the repair site
• Posterior tears cause bowel difficulty; anterior tears toward the urethra cause swelling and voiding difficulty
• Vaginal rugae return within 3 weeks

Assessment:

• Check the perineum with the fundus and lochia, then every shift using REEDA: redness, edema, ecchymosis, discharge, approximation
• Inspect anteriorly while supine, then side-lying with buttocks separated to see the perineum and check for hemorrhoids
• Expected: mild edema, minor bruising, edges approximated (most lacerations are internal), mild to moderate pain

Comfort and infection prevention:

• Ice or cold sitz bath for the first 24 to 48 hours (vasoconstriction reduces edema and numbs)
• Warm sitz baths after 24 hours, twice a day for 20 minutes (circulation and healing)
• Side-lying; tighten the gluteal muscles when sitting down
• Snug pads, topical anesthetics, analgesics; reassess pain 30 minutes after a dose
• Peri-bottle with warm water after every elimination; change pads often; wash hands

E. Pain management (Clinical Judgment)

• Sources: afterpains, perineal trauma, cesarean incision, nipple pain from poor latch, engorgement, hemorrhoids, general soreness
• Assess with VS, on complaint, before and after painful procedures and interventions. Culture shapes pain expression; number and faces scales may not work across cultures
• Nonpharmacological: ice packs, warm compresses, aromatherapy, sitz baths, repositioning, walking, showering, witch hazel pads, anesthetic spray
• Ibuprofen 400 to 600 mg PO every 4 to 6 hours PRN, max 3,200 mg/day; give with food or milk and a full glass of water. Hypersensitivity risk with asthma, nasal polyps or aspirin allergy
• Acetaminophen 650 mg every 4 hours PRN
• Opioids only for moderate to severe pain not relieved by the above; combine with a nonopioid and keep the course short (constipation, persistent use)

F. Breasts

• After birth, estrogen and progesterone fall and prolactin rises; prolactin drives milk production
• Suckling causes posterior pituitary release of oxytocin, which triggers let-down (milk ejection)
• Primary engorgement around day 3 in both breastfeeding and nonbreastfeeding women; breasts larger, firm, warm, tender, throbbing; subsides in 24 to 48 hours. Later engorgement comes from missed feedings or poor milk removal
• Colostrum: yellow; more protein and less carbohydrate than mature milk; contains IgG and IgA; lasts 5 days to 2 weeks before transition to mature milk
• Primary complication of breastfeeding: mastitis

Expected breast findings (both groups): day 1 soft and nontender; day 2 slightly firm and nontender; day 3 firm, tender and warm.

Box 12-3, breast care:

• Physiological engorgement: swollen breasts
• Pathological engorgement: hard, swollen, red, tender, warm, throbbing; may have a low fever; infant may not latch
• Breastfeeding treatment: frequent feedings to empty breasts; warm compresses and massage before feeding; pump or hand-express if the infant cannot nurse; ice packs after feeding; analgesics; supportive bra
• Nonbreastfeeding prevention and treatment: supportive bra (or sports bra) 24 hours a day until soft; avoid breast stimulation, expressing milk and heat (all stimulate production); ice packs; analgesics; subsides in 48 to 72 hours. Leakage, pain and engorgement may occur days 1 to 4
• Plugged ducts: pea-sized tender lumps from poor emptying; treat with frequent feeds, changing positions, warm compress or shower and massage before feeding. Unresolved, they can lead to mastitis and abscess
• Nipples: check before feeds for cracks, blisters and redness; air-dry after feeds; correct poor latch. Nipple soreness is a main reason women stop breastfeeding and breakdown is a portal for bacteria

Mastitis:

• Usually 3 to 4 weeks after birth
• Causes: bacteria through cracked nipples; milk stasis, engorgement, long intervals between feeds, stress, fatigue
• Signs: fever, chills, malaise, flu-like symptoms, UNILATERAL breast pain, redness and tenderness
• Treatment: empty the affected breast, antibiotics (milk culture may be ordered first), analgesia, rest, nutrition, fluids
• Continue breastfeeding or pumping; moist heat to the breast before feeding

III. Cardiovascular and Hematologic System

• Average vaginal blood loss 200 to 500 mL; tolerated because of pregnancy hypervolemia
• Stroke volume and cardiac output rise in the first hours as uteroplacental blood returns. CO stays elevated for 24 to 48 hours and is back to baseline by 10 days
• Plasma volume falls, then rises with fluid shifts; transient anemia resolves by 8 weeks
• WBC may rise to 30,000/mm3 within hours of birth (stress of labor) and normalizes within 7 days
• Clotting factors stay elevated and return to normal within 2 weeks: VTE risk, and PE is the life-threatening complication
• Orthostatic hypotension risk is highest in the first week (low pelvic vascular resistance)
• Postpartum chills (shaking in the first hours) come from vascular instability and are normal if the temperature is normal

Nursing actions:

• Pulse and BP on the standard schedule (q15 min x1 hr, q30 min x1 hr, q4h x22 hr, then every shift)
• Transient BP rise of about 5% is normal. Bradycardia is normal early postpartum. Tachycardia may mean blood loss, fever or infection
• Chills with a normal temperature: warm blanket and reassurance. Chills with fever: evaluate for infection and notify the provider
• Check calves and groin each shift for tenderness, edema and warmth; compare pulses; measure calf width if DVT is suspected. DVT signs: pain, tenderness, redness, warmth, a hard cord-like vessel, swelling
• Orthostatic precautions: rise slowly; assist with ambulation for the first 24 hours; sit or lie her down if dizzy; ammonia ampule if she faints
• Labs: Hgb drops 1 to 1.5 g/dL and Hct drops 3% to 4% per 500 mL blood loss
• Postpartum anemia: Hgb under 11 g/dL and Hct under 32%; treat with oral ferrous sulfate
• VTE prevention: early and frequent ambulation, no leg crossing, compression stockings if she has a history of clots

IV. Respiratory System

• Chest wall compliance returns once diaphragm pressure is relieved; back to baseline by the end of the postpartum period
• RR on the standard schedule; normal 12 to 20/min; SpO2 95% or higher; breath sounds clear
• Pulmonary edema risk: oxytocin, large IV fluid volumes, tocolytics (magnesium sulfate, terbutaline), multiple birth, infection, preeclampsia, bedrest

V. Immune System

• Immune suppression of pregnancy resolves
• Mild temperature elevation in the first 24 hours is common (exertion, exhaustion, dehydration, hormones)
• Under 100.4 F (38 C) in the first 24 hours: push fluids (8 to 10 glasses, at least 64 oz/day), rest, reassess in 1 hour
• 100.4 F (38 C) or higher on two occasions after the first 24 hours suggests infection: notify the provider, anticipate workup, and notify the nursery
• Postpartum vaccines: rubella (MMR) if nonimmune, Tdap, hepatitis B, varicella, influenza

Rubella immunization:

• First-trimester rubella has a 90% transmission rate; fetal effects include deafness, blindness, heart defects and intellectual disability
• Give to rubella-nonimmune women before discharge (consent may be required); MMR is often used
• Avoid pregnancy for 4 weeks after the vaccine

Rh isoimmunization:

• An Rh-negative woman exposed to Rh-positive blood (transfusion or an Rh-positive fetus) makes IgG anti-D, which crosses the placenta and hemolyzes fetal RBCs. It is preventable
• Rho(D) immune globulin is given at 28 weeks
• Postpartum: if the baby is Rh positive and the mother is Coombs negative, give a second dose within 72 hours of birth
• RhoGAM 300 mcg IM only, or Rhophylac 300 mcg IV or IM; do not confuse the IM and IV products
• Confirm mother Rh negative and infant Rh positive before giving

VI. Urinary System

• Transient stress incontinence may last up to 6 weeks; risk factors include multiparity, perineal trauma, large infant, long second stage, pushing technique
• Primary complications: bladder distention and cystitis
• Causes of distention and retention: IV fluids, anesthesia or analgesia (reduced urge), urethral edema, lacerations or episiotomy, operative delivery, bladder trauma
• Diuresis starts within 12 hours of birth (falling estrogen); output may reach 3,000 mL/day

Nursing actions:

• Help her void within 2 to 4 hours of birth; expect at least 300 mL per void
• Voids under 150 mL: palpate for distention (urinary retention). Signs: uterine atony, uterus above the umbilicus and to the right, increased lochia, suprapubic fullness. Bladder scan if available
• Cannot void with an overdistended bladder: catheterize. Indwelling catheter for 24 hours if the cause is edema; straight cath if little edema and repeat caths are not expected
• Peppermint oil on a cotton ball in the collection hat relaxes the urinary sphincter
• Frequency, urgency or burning suggests cystitis: notify the provider
• Fluids at least 10 glasses a day
• Cystitis: frequency, urgency, burning, suprapubic tenderness, hematuria, malaise; treat with antibiotics, fluids, rest
• Evidence-based practice: about one-third of women have incontinence in the first 3 months. Pelvic floor muscle training (Kegels): 8 contractions with 8-second holds, 3 times a day, 3 days a week, for at least 3 months

VII. Endocrine System

• Estrogen, progesterone and prolactin fall after placental delivery; estrogen starts rising after week 1
• Nonlactating women: prolactin declines over 3 weeks; menses returns at 7 to 9 weeks; first cycle usually anovulatory; ovulation returns at about 10 weeks on average
• Lactating women: suckling raises prolactin and suppresses menses; ovulation returns at about 17 weeks on average
• Ovulation can precede the first period, so both groups need contraception when intercourse resumes. Breastfeeding is not reliable contraception
• Diaphoresis: night sweats in the first weeks from falling estrogen, excreting pregnancy fluid. Check temperature to rule out infection; cotton nightwear; teach her to tell sweating from fever

VIII. Muscular and Nervous Systems

• Diastasis recti abdominis: separation of the rectus muscles, felt during fundal checks; reassure that it lessens over time
• Muscle soreness from positioning and pushing: ice for 15 minutes, heat, warm shower, analgesia
• Epidural or spinal: reduced lower-body sensation for several hours; delay or assist ambulation until full sensation returns (fall risk)
• Headache: assess location and quality. A post-dural puncture headache from CSF leak is worse upright and better lying flat. Headache can also signal preeclampsia; notify the provider for either
• Fatigue: promote rest, nap when the baby sleeps, cluster care, treat pain

IX. Gastrointestinal System

• GI tone and motility return to normal by the end of week 2; bowel function usually returns in 2 to 3 days
• Constipation risks: progesterone, inactivity, dehydration, fear of a BM after perineal trauma, perineal pain
• Hemorrhoids: common; witch hazel pads, topical anesthetics, sitz baths, side-lying instead of prolonged sitting
• Appetite: very hungry; regular diet unless otherwise ordered; snacks between meals
• Weight loss: about 11 to 12 lb at birth plus 5 to 8 lb from diuresis; on average about 3 lb above prepregnancy weight at 6 months

Nursing actions:

• Assess bowel sounds each shift; report faint or absent sounds (risk of obstruction)
• Ask about BMs; offer water and prune juice; fluids of 3,000 mL/day; fiber; ambulation; stool softener or laxative as ordered
• Ask about nausea and vomiting (common with opioids)
• Respect cultural food preferences; families may bring food from home

X. Follow-Up Care and Discharge Teaching

• See the maternal care provider within the first 3 weeks, with a comprehensive visit by 4 to 6 weeks (about 40% of women miss the postpartum visit)
• Comprehensive visit: physical, social and psychological assessment; EPDS depression screen; birth spacing and contraception (including LARC); vaccines; pain, incontinence, dyspareunia, fatigue, mood and feeding concerns
• Breastfeeding women need 500 to 1,000 extra calories a day and about 2 to 3 L of fluid
• Spread teaching over the whole stay rather than leaving it to discharge day

AWHONN POST-BIRTH warning signs:

• Call 911: chest pain; obstructed breathing or shortness of breath; seizures; thoughts of hurting herself or the baby
• Call the provider: bleeding that soaks one pad an hour or a clot the size of an egg; an incision that is not healing; a red, swollen, warm or painful leg; temperature 100.4 F (38 C) or higher; a headache that does not improve with medicine, or a bad headache with vision changes
• If the provider cannot be reached, go to the emergency room

Signs to report and what they mean:

• Heavy lochia (a pad an hour), a return to bright red bleeding, or egg-size clots: secondary PPH
• Foul-smelling lochia, fever, pelvic or abdominal pain: infection
• Frequency, urgency, burning: cystitis
• Unilateral breast tenderness with a warm red area, chills and fever: mastitis (3 to 4 weeks)
• Blurry vision, severe headache, epigastric pain, fluid retention: preeclampsia
• Leg pain, swelling and redness: DVT. Chest pain and dyspnea: PE
• Thoughts of harm, trouble caring for self or infant, sleep problems, persistent sadness: postpartum depression

Other teaching:

• Self-care: perineal care and pad changes until lochia stops; breast care; pain control
• Expected changes: involution, afterpains, lochia, engorgement, diaphoresis, diuresis, weight loss
• Nutrition: MyPlate; iron-rich foods for anemia (leafy greens, beans, red meat, poultry, fortified cereal, raisins); roughage for constipation
• Activity: at least 150 minutes a week of moderate activity such as brisk walking, in bouts of at least 10 minutes; Kegel exercises
• Rest: nap when the baby naps, prioritize, take vitamins, iron and pain medication as ordered
• Sexual activity: resume when lochia has stopped, the perineum has healed and she feels ready; lubricant for dryness; use contraception
• Smoking: most women who quit for pregnancy relapse after birth; encourage abstinence, offer resources, no smoking around the infant
• Schedule the postpartum visit before discharge

XI. Contraception (Table 12-3)

AWHONN supports insurance coverage for all FDA-approved contraceptives (Critical Component).

XII. Clinical Pathway: Uncomplicated Vaginal Delivery

• Labs: RPR, hepatitis B surface antigen, rubella, blood type and Rh; fetal Rh if mother is Rh negative; CBC as ordered; GBS documented; urine toxicology per policy
• Activity: assist first ambulation, especially after an epidural, until sensation and motor function return
• Measure the first 2 voids; notify CNM or MD if output is under 30 mL/hr. If she cannot void or voids under 150 mL with the uterus above the umbilicus and deviated, consider catheterization
• Ice to the perineum for the first 24 hours; pericare with each void
• Stop IV oxytocin when the fundus is firm and lochia is normal
• Give rubella vaccine and Rh immune globulin as indicated before discharge
• Discharge criteria: VS normal; fundus firm, midline and descending 1 cm a day; lochia moderate to scant; perineum healing; voiding and bowel function normal; breastfeeding going well; family verbalizes warning signs and follow-up

High-Yield Numbers

• Postpartum period: 6 weeks; involution 6 to 8 weeks
• Assessment schedule: q15 min x 1 hr, q30 min x 1 hr, q4h x 22 hr, then every shift
• Fundus: at or 1 cm above the umbilicus by 12 hours; 1 cm below at 24 hours; drops 1 cm a day; not palpable by day 14; 1 fingerbreadth = 1 cm
• Massage, then reassess in 5 to 10 minutes
• Primary PPH under 24 hours; secondary 24 hours to 12 weeks, peak days 7 to 14
• Lochia rubra days 1 to 3, serosa 4 to 10, alba 10 on
• Heavy: a pad in 1 hour; excessively heavy: a pad in 15 minutes
• 1 g = 1 mL blood loss
• Average vaginal blood loss 200 to 500 mL
• Hgb drops 1 to 1.5 g/dL and Hct 3% to 4% per 500 mL lost
• Anemia: Hgb under 11 g/dL, Hct under 32%
• WBC up to 30,000/mm3, normal by day 7
• Clotting factors normal within 2 weeks; cardiac output normal by 10 days
• Fever: 100.4 F (38 C) twice after the first 24 hours
• Void within 2 to 4 hours, at least 300 mL; under 150 mL means check for retention
• Diuresis within 12 hours, up to 3,000 mL/day
• Ice for 24 to 48 hours; warm sitz baths after 24 hours, 20 minutes twice a day
• Engorgement around day 3; mastitis at 3 to 4 weeks
• Rho(D) immune globulin within 72 hours; 300 mcg
• Avoid pregnancy 4 weeks after rubella vaccine
• Ovulation returns about 10 weeks (not breastfeeding) vs 17 weeks (breastfeeding)
• Lactation: plus 500 to 1,000 kcal/day and 2 to 3 L fluid
• Ibuprofen max 3,200 mg/day

Priority Nursing Actions and Red Flags

• Boggy fundus: massage first, then oxytocin per order, then notify
• Fundus high and deviated to the right: full bladder; void first, then reassess
• Heavy bleeding with a firm fundus: suspect laceration or hematoma
• Saturating a pad in 15 minutes or meeting any early warning criterion: urgent bedside evaluation; IV access, oxygen, frequent VS, rapid response
• Support the lower uterine segment during fundal checks to prevent inversion
• Tachycardia is an early sign of hemorrhage; BP drops late
• Fever after the first 24 hours: notify the provider and the nursery
• Unilateral calf pain, warmth or swelling: DVT; sudden dyspnea or chest pain: PE (call 911)
• First ambulation: assist (orthostatic hypotension, epidural); if she faints, lay her down
• Postural headache after an epidural: post-dural puncture headache; headache with vision changes or epigastric pain: preeclampsia
• Confirm Rh status of mother and infant before RhoGAM; never give RhoGAM IV

Medications

Related

• nsg210-durham-ch13-transition-to-parenthood
• nsg210-durham-ch14-high-risk-postpartum
• Cesarean care (Durham Ch. 11) is in the labor and birth study sheet: nsg210-exam-2-labor-birth-study-sheet
• INDEX