Module 8: Postpartum and Transition to Parenthood Flashcards
(82 cards)
1
Q
What kind of questions could you ask parents to assess their initial adaptation to parenting?
A
- Tell me about your labour and birth?
- Was it what you expected?
- Do you have any questions about the experience?”
- It can also be helpful to specifically ask the father, “and how was it for you?”
2
Q
What are 3 topics of maternal postpartum care?
A
- promoting maternal health
- providing education
- preparing woman and family for discharge
3
Q
What are 4 maternal assessments done in the first 24 hours postpartum?
A
- vital signs
- fundus- position and tone
- flow- amount, color, consistency
- perineum- swelling, pain, stitches
- bladder- voiding
- bowel- last BM, does she need stool softener?
- breasts
- pain- perineal pain? Incisional pain post C/S
- legs (for thrombosis)
- nutrition and hydration
- support systems
- emotional status
- readiness for self-care
- readiness for baby care
4
Q
What is the acronym BUBBLES?
A
- Breasts
- Uterus
- Bowel
- Bladder
- Lochia
- Episiotomy
- Supports
5
Q
What is the average blood loss for vaginal birth? Caesarean birth?
A
- physiologic changes of pregnancy, mainly increased blood volume, enable the woman to deal with the normal blood loss that occurs after birth
- vaginal birth is 300-500 ml
- caesarean birth it is 500-1000 ml
6
Q
What is involution? How is it assessed?
A
- the return of the uterus to pre-pregnant state
- assessed by palpating the fundus and monitoring the vaginal flow
7
Q
What is the measurement of fundus at the end of third stage labour?
A
- the fundus should be approximately 2cm below the umbilicus and midline
- By 12 hours postpartum it can rise to 1cm above the umbilicus then
- by 24 hours it should be at or just below the umbilicus.
- It should descend by 1-2 cm every 24 hours
8
Q
What does it mean if the fundus is above umbilicus or deviated to the right?
A
- it may indicate a full bladder.
- A full bladder increases the risk of post-partum hemorrhage (PPH) as the uterus is not able to contract efficiently
9
Q
Why is the hormone oxytocin significant in postpartum period (uterus)?
A
- promotes involution by causing the uterus to contract and compress the blood vessels that fed the placental bed
10
Q
What colour is the uterine discharge first 2 hours after birth?
A
- uterine discharge is bright red and should be approximately the amount of a heavy period
- normal for small clots to be present.
- Uterine discharge is known as lochia and the amount and color changes over time
11
Q
What colour is lochia (uterine discharge) at 3-4days? 2 weeks? 4-8 weeks?
A
- Lochia rubra: is dark red and lasts for 3-4 days
- Lochia serosa: is pink or brown and lasts for 10-14 days
- Lochia alba: is yellow to white and may last up to 4-8 weeks
12
Q
What are 4 factors increase risks for perineal trauma (perineal lacerations)?
A
- poor maternal nutritional status,
- birth position,
- pelvic anatomy,
- fetal malpresentation and position,
- large infant,
- use of forceps or vacuum,
- prolonged second stage, or
- precipitate birth
13
Q
What is the acronym REEDA when assessing perineum tears or episiotomies in the postpartum period?
A
- when assessing the perineum in the post-partum period, it is important to turn the woman onto her side
- Redness,
- Edema,
- Ecchymosis,
- Discharge, and
- Approximation
14
Q
What is a hematoma?
A
- hematoma: is a collection of blood in the connective tissue
- a woman may develop a pelvic hematoma
15
Q
What are 3 pharmacological ways incisional pain from caesarean birth be managed?
A
- epidural opioids,
- patient controlled analgesia,
- IM, oral, or rectal analgesics including anti-inflammatories
16
Q
What are 3 interventions that happens by day 1 post op of caesarean birth?
A
- abdominal incision dressing may be removed
- normal diet resumed: as long as bowel sounds are present
- urinary catheter removed
17
Q
What 2 breastfeeding positions can mother use after caesarean birth?
A
- football hold or
- side lying
18
Q
What are 2 increased risks for women who had surgical delivery?
A
Increased risk of thromboembolism:
- to reduce risk: use of compression stockings or automated compression devices postpartum until the woman is fully mobile
Increased risk for wound infection:
- postpartum teaching,
- women need to be advised to look for redness, swelling, discharge, or increasing pain
- to notify their care provider immediately
19
Q
What is attachment?
A
- is a mutual process where the behaviours and characteristics of one elicit behaviours and characteristics of the other
- For example, a newborn’s cries should elicit a response from the parent. The response from the mother or parent elicits a response from the newborn (either settles or continues to cry.)
20
Q
What is the mothering hormone (1)?
A
- oxytocin:
- supports attachment by reducing maternal stress
- promoting maternal well-being which affects parenting behaviour
21
Q
What are 4 behaviours do you expect to see that would indicate positive attachment process?
A
- Reaching out for the infant,
- talking to the infant,
- calling the infant by name,
- smiling, kissing, and
- responding to crying by picking the infant up and
- cuddling
22
Q
What are 4 nursing strategies can you use to support attachment?
A
- Skin to skin care,
- acknowledging how the infant looks like one parent or the other,
- saying things like “look how he/she turns his/her head when you speak.
- Look how easily the baby settles in your arms.”
- Encouraging the parents to provide care such as bathing and changing diapers.
- Teaching the parents that attachment is reciprocal; that the infant will want to be held close and responding immediately to cries or fussiness builds trust and security
23
Q
What is maternal role attainment?
A
- immediate postpartum period is a time for women to recuperate from the birth and
- adjust to the realities of being a mother
- period of fundamental role adjustment,
24
Q
What are the 3 phases of maternal role attainment described by Rubin (1984)?
A
- taking in: 2-3 days (dependent: help me)
- taking hold: 3-14 days (independent: ive got to help myself)
- letting go: 15 days-6months (interdependent: we are all in this together)
25
What is the 4 phases of "becoming a mother" described by Mercer (students of Rubins)
- commitment, attachment to the unborn baby, and preparation for delivery and motherhood during pregnancy
- acquaintance/attachment to the infant, learning to care for the infant, and physical restoration during the first 2 to 6 weeks following birth
- moving toward a new normal
- achievement of a maternal identity through redefining self to incorporate motherhood (around 4 months)
26
What are 4 maternal factors would affect the time frames and achievements of the phases in "becoming a mother"
- maternal age
- relationship with the father of the child
- socioeconomic status
- cultural practices
- perception of the birth experience
- early mother-infant separation
- social stress
- social support
- personality traits (temperament, empathy, and rigidity)
- self-concept
- child-rearing attitudes
- perception of the infant
- role strain
- health status
Infant variables included:
- temperament
- appearance
- responsiveness
- health status
27
What 4 signs/observations of adjusting parents that would be concerning during postpartum period?
- unable or unwilling to discuss labour and birth
- refers to self as ugly or useless
- excessively preoccupied with body image
- markedly depressed
- lack of support system
- partner or other family members react negatively to the infant
- refusal to interact with or care for the newborn
- expressed disappointment over the sex of the newborn
- views newborn as messy or unattractive
- baby reminds parents of someone they don’t like
- difficulty sleeping
- loss of appetite
28
What are 4 newborn care education topics to be discussed during discharge?
- importance of skin to skin
- newborn feeding: breastmilk, formula storage, preparation, cue based feeding
- behaviours: sleep wake states
- infant crying: shaken baby syndrome prevention
- safe sleep environment: back to sleep
- infant care: cord care, bathing, tummy time, consoling techniques, S&S jaundice, car seat safety, weight lost/gain, immunization, communicable disease
29
What are 4 care education topics for mothers to be discussed during discharge?
- rest and activity
- post partum blues, depression
- self care: fundus, hygiene, nutrition, pain management, contraception, perineum care, incision care,
- newborn feeding: breast, nipple care, engorgement
- smoke free environment
- Normal physiological changes
30
Are cars eat safety checks done at hospital?
- yes upon discharge
- Car seat checks (ensuring proper positioning and anchoring) are performed
31
What is the position for infant safe sleep?
- all infants should be placed on their backs for sleep (supine not prone position)
- The “Back to Sleep” reduced number of Infant Death syndrome (SIDS) death
32
What sleep position increase incidence of "flat head"
- supine
- flat head: medically referred to as plagiocephaly
- supervised tummy time when awake is recommended
33
What is Sudden Infant Death Syndrome (SIDS)?
- is defined as the sudden death of an infant less than one year of age that remains unexplainable after a thorough case investigation
- higher number of SIDS deaths occurs during the winter months and at 2–3 months of age
- Preterm infants also have an increased risk of SIDS
34
What are 4 preventions for SIDS?
- Healthy normal infants: placed on back to sleep.
- If a side-lying position is used: dependent arm should be brought forward to lessen the likelihood of the infant rolling over to the prone position.
- crib mattress should be firm and tight fitting: crib should also be kept free of bumper pads, pillows, and other soft products.
- If a blanket or sheet is used: firmly tucked under the mattress and only cover the baby to his/her chest. Sleeping clothes alone should be considered to keep the baby warm.
- Infants should be dressed and covered in a manner that prevents overheating.
- Infants should be cared for in a smoke-free environment.
- Co-sleeping should be used with caution - never on a soft surface, in contact with soft bed covers, and never when the co-sleeper is a smoker or affected by alcohol, drugs, or medication.
35
What is shaken baby syndrome (SBS)?
- baby/child being roughly shaken back and forth, causing brain and cervical injuries
- is a violent form of child abuse that can permanently damage a child
- leading cause of non-accidental infant death during the first year of life
- most common instigator of this abusive treatment is infant crying and it is important that all new parents receive information on coping strategies to deal with their frustration and anger when their baby is crying
36
What are the 3 actions of Period pf Purple Crying program includes when faced with infant crying?
- Responding to the baby with “comfort, carry, walk and talk” behaviours
- Putting the baby in a safe place and then walking away
- Never shaking or hurting the baby to stop its crying
37
What would you tell parents about newborn screening when they are discharged home with their newborn within 24hours of birth?
- You could explain to parents that the ideal time for infant screening is between 24 to 48 hours because of the time sensitivity with some of the metabolic diseases (PKU and MCAD).
- Parents who are discharged home early may be given the choice to have a preliminary screen done on their newborn.
- However, this will have to be followed up with a further test within 7 days.
- The other choice would be to take their newborn to a laboratory or hospital that can perform the screening the day after discharge
38
What 4 information would you give to new parents about safe sleep practices for their newborn?
- Placing the newborn on his/her back for sleep.
- safest place for an infant to sleep is alone in a crib.
- The crib should have a tight fitting, firm mattress,
- be free of any soft bedding such as pillows and bumper pads.
- Dress the infant for sleep with suitable clothing, avoiding the need for blankets and other bed covering.
- Infants should be cared for a in a smoke-free environment.
- Side lying and prone positions, although discouraged as sleeping positions, may be used for short periods with supervision.
- Health Canada (2008) states that bed sharing with an adult or other child presents a sleep-related hazard. The risk is higher if the co-sleeper is a smoker or under the influence of drugs or alcohol
39
What are 4 infant consoling techniques that you teach new parents?
Consoling techniques that may help are:
- swaddling
- walking
- talking to
- rocking
- It is important to tell parents that even after his/her physical needs are attended to; the baby may still be fussy and need some consoling time.
- Parents needs to know that infant crying often increases around two months and may be more persistent in the evening.
- Reassurance should also be given that infant crying after his/her needs are met does not necessarily reflect that their caregiving is inadequate.
- Some babies do cry more than others
40
What 4 information do you think might be helpful for new parents regarding their emotional responses to infant crying?
- It is important to tell parents that being the parent of a newborn is physically and emotionally demanding and they should check on their reactions and responses to their newborn crying.
- If your baby continues to cry after you’ve made sure there’s no specific problem, try to stay calm and check your state of mind. Are you upset? Are you frustrated?
- If you feel like you might lose control, stop! Place your child safely in the crib, take timeout, and leave the child’s room for a few minutes.
- If you feel like you may hurt your baby, call for help: a partner, friend, family member, a crisis line or community health agency, a welfare agency, or police.
The CPS offers the following tips for parents who have a baby that cries a lot:
- Make arrangements for regular child care relief and get some rest.
- Form a backup plan for calling in reliable help when your baby’s crying seems impossible to deal with.
- Talk to a friend, family member, counselor, or health professional about your situation.
- Know your caregiver. Never leave a child with someone you don’t trust, or someone who has violent reactions.
- Never shake your baby.
41
When are postpartum follow up care done after discharge?
- Midwives provide postpartum care up until 6 weeks postpartum. Generally, the midwife performs an initial 1-2 visits at the woman’s home and provide in person and telephone support weekly as needed.
- Family physicians continue with mother/infant care throughout the postpartum period and as long as the family remain part of the practice.
- Obstetricians will see a woman for a 6 week checkup, but they do not provide infant care.
42
When do community health nurses provide care after discharge?
- goal is for all women to receive a telephone call within 48 hours after discharge
- the need for an in home visit can be determined
43
What type of families are prioritized to have early visit from public health nurses (4)?
- Families dealing with substance use
- New immigrants
- Lower socioeconomic status
- Adolescent mothers
- Families with multiples (twins or higher order multiples)
44
What is Rhesus (Rh) factor?
- Rhesus (Rh) factor is a group of proteins that occurs on the surface of some people's red blood cells.
- If you have Rh factor on your red blood cells, you are referred to as Rh-positive.
- If you do not have Rh factor, you are Rh-negative
45
Why is additional interventions in postpartum care needed for mother who is Rh negative?
- Rh incompatibility, or isoimmunisation (also known as alloimmunization), occurs when an Rh-negative mother has an Rh-positive fetus who inherits the dominant Rh-positive gene from the father
- If the fetal Rh-positive red blood cells pass through the placenta into the maternal circulation her immune system will produce antibodies against the Rh-positive antigen.
- This is known as sensitization and can occur during pregnancy, birth, miscarriage, therapeutic abortion, amniocentesis, external cephalic version, caesarean birth, placental abruption, manual removal of placenta and trauma
- This sensitization does not usually cause problems during the first pregnancy, but becomes more problematic in subsequent pregnancies when more antibodies develop with repeated contact with the Rh-positive antigen. This may result in Rh hemolytic disease in the unborn baby.
46
What treatment/intervention happens for Rh negative mother?
- Women who are Rh negative usually receive one prophylactic dose of Rh immune globulin at 28 weeks of pregnancy.
- Rh-negative women would also receive the immune globulin within 72 hours if they experience any of the situations listed above (miscarriage, abruption etc).
- This injection of anti-Rh antibodies destroys any fetal RBCs in the maternal circulation and blocks maternal antibody production
47
What are 4 communicable disease?
- Hepatitis B
- Hepatitis C
- HIV
- Rubella
48
What treatment/intervention is done for HepB for infant?
- Hepatitis B is a disease of the liver that is caused by a virus that is transmitted by exposure to infectious blood, semen or body fluids.
- A pregnant woman can pass hepatitis B to her unborn baby during delivery
- baby born to a mother who is infected with hepatitis B or whose mother is a chronic carrier must be immunized at birth with a Hepatitis B vaccine and Hepatitis B immunoglobulin (HBIG).
- The remaining booster shots are then given at 2, 4, and 6 month immunization appointments
49
What are 4 risk factors for HepC?
- history of blood transfusions,
- multiple sex partners,
- IV drug use, and
- history of sexually transmitted infections (hepB and HIV)
50
What is HIV? What treatment done for infant?
- infection results in severe compromise to the immune system which increases the risks of other opportunistic diseases
- HIV testing is offered to all pregnant women during pregnancy
- Infants of HIV positive mothers receive antiretroviral medication after birth and up 6 months of age.
- Breastfeeding is contraindicated in Canada for HIV positive mothers
51
What is Rubella? What treatment/intervention is done for mother?
- contagious viral infection best known by its distinctive red rash
- known as German measles is an infection that primarily affects the skin and lymph nodes
- caused by the rubella virus which is usually transmitted by droplets from the nose or throat, however it can also cross the placenta and cause congenital rubella syndrome in developing babies
- If the mother has not been immunized against rubella, or had a low antibody titre identified in her antenatal screen, it is recommended that she receive a rubella immunization in the postpartum period
52
What is postpartum hemorrhage (PPH)?
Defined as blood loss of:
>500 ml for a vaginal birth and
>1000 ml for caesarean birth
- Early or acute PPH occurs within 24 hours of birth while late: associated with uterine atony
- Secondary PPH may occur up to 6 weeks postpartum: result of retained tissue or infection
- life-threatening event that can occur with little warning
- leading cause of maternal morbidity and mortality worldwide
53
What is uterine atony? What is it associated with (4)?
- failure of the uterus to contract sufficiently
Associated with:
- high parity,
- multiple gestation,
- macrosomic infant,
- prolonged or precipitate labour
- use of oxytocin for induction or augmentation
54
What are causes of postpartum hemorrhage under 4Ts?
- Tone: anything that affects the ability of the uterus to contract (over distended uterus, large fetus, long labour, full bladder)
- Tissue: retained placenta or fragments of placenta
- Trauma: forcep or vacuum assisted birth, tears
- Thrombin: coagulation disorders
55
What is your immediate nursing response when a PPH is evident (8)?
- Stay with the woman and call for help.
- Assess maternal ABC’s
- Establish intravenous access
- Massage fundus, determine most likely cause (4Ts)
- Ensure bladder is empty
- Keep the woman NPO
- Ongoing assessments of vital signs, fundus, and measurement of blood loss
- Anticipate and prepare for administration of oxytocin, lab work and possible OR
56
What 4 factors woman indicate as a birth trauma?
- when there has been a threat of injury or death to the woman or her baby,
- when interventions have occurred unexpectedly
- how women have been treated by health care providers (treated inhumanely or in a degrading manner)
- feeling invisible or out of control
57
What is postpartum blues?
- type of depression that happens after giving birth
- Common symptoms are labile emotions, tearfulness, feeling let down, restlessness, insomnia, fatigue, headaches, anxiety, or anger.
- These symptoms are usually transient beginning on the third or fourth day after birth, lasting one to two weeks, then disappearing without any treatment.
- Women with postpartum blues frequently do not know why they feel depressed and will talk of feeling “silly” while laughing through their tears
- Factors that may contribute to postpartum blues include inadequate emotional support from their partners or feeling overwhelmed by new mothering responsibilities.
58
What is postpartum depression (PPD)?
- Usually, it begins within two weeks to six months of birth.
- PPD is more serious than postpartum blues with intense and pervasive sadness and severe mood swings
- Symptoms of intense fear, anger, anxiety
- Other symptoms: poor appetite, excessive sleeping or inability to sleep, irritability, and uncontrollable crying
59
What are 4 risk factors for postpartum depression (PPD)?
- Unplanned pregnancy
- History of major depressive episode
- Lack of social support
- Prenatal anxiety or depression
- Complicated pregnancy or birth
- Life stress
- Major life event (moving, divorce, job loss)
- Marital problems
- Abuse
- Diabetes
- Women who have undergone fertility treatments
- Preterm or sick infant
- Mothers of multiples
- Low socioeconomic status
60
What are 3 supportive treatments for postpartum depression?
- self-help groups,
- respite care,
- counseling,
- home assistance,
- coaching regarding interacting with her infant
61
What is postpartum psychosis?
- most severe form of postpartum depression
- Typical postpartum psychosis episodes include: auditory or visual hallucinations, paranoia, delirium or disorientation, and impulsive thoughts and actions
- Poor judgment and impulsiveness increases the risk of suicide and infanticide
62
How can you present information on postpartum blues, depression, and psychosis to parents during discharge teaching?
- written material for women but is also important to discuss that it is normal to feel emotional and anxious in the first couple of weeks but if this persists for more than a couple of weeks or if mom feels depressed, anxious, or like she is having trouble coping to contact her care provider.
- Let them know that many women feel guilty about feeling sad and it is very important to talk openly and seek support.
- It would be good to ask what kind of support they have and to encourage mom to join a new mothers group if there is one in her community.
63
What are the normal vital signs after birth?
- Temperature: can increased to 38 as a result of dehydration effects of labour
- Pulse: remains elevated for the first hour
- Respirations: slightly increase during pregnancy should be within normal range after birth
- Blood Pressure: transient increase over first few days after birth
64
What is important for preventing excessive bleeding (2)?
- maintaining good uterine tone
- preventing bladder distention
65
What is the cause of uterine atony?
- not always clear
- often results from retained placental fragments
66
How is blood loss subjectively described as?
- assessed by extent of perineal pad saturation (1ml=1g)
- scant: <2.5cm
- light: <10cm
- moderate: >10cm
- heavy (profuse): one pad saturated within 2 hours
67
What intervention to alleviate uterine atony and restore uterine tone?
- stimulation by gently massaging the fundus until firm
68
What are 4 techniques to help woman void (to prevent bladder distention)?
- full bladder: causes uterus to be displaced about umbilicus and prevent uterus from contracting normally
- assist women to bathroom/bedpan
- have women listen to running water
- placing womans hands in warm water
- pouring water from squeeze bottle over her perineum
69
What are 4 non-pharmacological interventions for postpartum discomfort/pain?
- distraction
- imagery
- aromatherapy
- music therapy
- TENS
- massage
- heating pad
- ice packs
- lying on her side when possible
70
What are 3 types of pharmacological interventions for postpartum discomfort/pain?
- NSAIDS: ibuprofen or naproxen
- anesthetic ointment (if had perineal repair)
- PCA or epidural analgesia (after caesarean birth)
71
When is the ideal time to breastfeed?
- first 1-2 hours after birth
- newborns place in skin to skin contact
- breastfeeding aids in contracting the uterus and preventing maternal hemorrhage
72
What are 3 ways to prevent venous thromboembolism (VTE)?
- early ambulation
- antiembolic stockings (TED hose)
- sequential compression device (SCD)
- exercise legs in bed
73
What are 4 parents "facilitating behaviours" in regards to parent-infant attachment?
- looks, gazes
- hovers: directs attention to infant
- identifies infant as unique individual
- claims infant as family member
- names infant
- touches/smiles at infant
- express pride in infant
74
What are 4 parents "inhibiting behaviours" in regards to parent-infant attachment?
- turns away from infant
- avoids infant
- maintains bland countenance or frowns at infant
- express disappointment in infant
- does not incorporate infant into life
- makes on effort to interpret infants actions/needs
- views infant behaviour as exploiting/uncooperative
75
What are the predictable 4 phases men go through as they transition to parenthood?
- first phase: enter parenthood with intentions of being involved father with deep connections to infant (expectations and intentions)
- second phase: confronting reality, realize expectations were inconsistent with the realities of life with a newborn
- third phase: working to create the role of involved father
- final phase: reaping rewards (infant smile)
76
What are the 3 ways infant-parent interaction can be facilitated?
- modulation rhythm: both parent and infant must be able to interact (alert state)
- modifications of behavioural repertoires: peek a boo game (if baby smiles so does the parent)
- mutual responsivity: responses in form to a stimulus behaviour (ex. infant smiling are viewed as contingent responses)
77
What are 4 events that could identify to have caused woman to develop antibodies to Rh factor?
- previous pregnancy with Rh-positive fetus
- transfusion with Rh-positive blood (which causes sensitization)
- ectopic pregnancy,
- miscarriage,
- induced abortion after 8 weeks or fetal death
- chorionic villus sampling or amniocentesis
- placental abruption
- external cephalic version
- trauma
78
Why is it important to determine/identify woman with Rh-negative
- ONLY Rh-positive fetus of Rh-negative mother is at risk
- fetal RBCs that contain Rh antigen pass through placenta into maternal circulation of Rg-negative mother
- maternal immune system produces antibodies against foreign fetal antigens
- usually Rh negative women become sensitized in their first pregnancy with Rh-positive fetus but do not produce enough to cause lysis of fetal blood cells
- during subsequent pregnancies: antibodies form in response to repeated contact with the antigen from fetal blood and lysis of fetal RBC results
- to prevent sensitization
79
What is Rh immune globulin?
- commercial preparation of passive antibodies against Rh factor
- this injection of anti-Rh antibodies destroys any fetal RBCs in maternal circulation and blocks maternal antibody production
- Rh immune globulin is 90% effective in prevention sensitization
- given at 28 weeks and within 72 hours of delivery after invasive procedure, miscarriage, induced abortion, ectopic pregnancy
80
What is paternal perinatal depression (PPND)?
- the best predictor is having a partner with postpartum depression
- other risk factors: age younger than 25 years, unmarried status, low socioeconomic status , family and social stressors
- display: fatigue, frustration, anger, irritability
81
What are 4 teaching for self-management in preventing postpartum depression?
- deep breathing, meditating
- eat balanced diet
- sleep as much as possible
- get out of house: try to leave home for 30mins
- share feelings with someone close
- dont place unrealistic expectations on yourself
- be flexible with activities
- go to new mothers support group
82
What is the priority response when a PPH is suspected?
- Call for help,
- assess vital signs,
- ensure venous access,
- massage the fundus
