1. Postpartum Flashcards
Three divisions of the uterus
1) Corpus (Fundus)
2) Isthmus
3) Cervix (Neck)
What is the isthmus?
The lower uterine segment
Early 20th century word for postpartum
Puerperium
Two types of physiologic changes during the postpartum period
Retrogressive: Uterus
Progressive: Nipples
Duration of postpartum period
6 weeks or 42 days
The rapid return of the uterus to the non-pregnant state refers to what?
Uterine involution
What causes uterine involution?
Endogenous oxytocin released from the pituitary
Two main processes involved in uterine involution:
1) Contractions of the uterine smooth muscle fibers
2) Contractions continue reducing the size of the uterus
What is one result of the uterine contractions (of the smooth muscle fibers)?
o In time, thrombi form within the uterine wall and permanently seal the area.
Fundus location: Immediately post-partum
Halfway between the symphysus pubis and the umbulicus
Fundus location: 12 hours post partum
One finger ABOVE the umbilicus
How quickly does the fundus descend?
- In the first 12 hours, it ascends a little
- After that, it will descend 1-2 fingerbredths every 2 hours
Where should the fundus be 24 hours postpartum?
At 24 hours, the fundus should be at umbilicus or one finger breadth (cm) below the umbilicus.
How much time does it take before the fundus is no longer palpable? What factor might speed this up.
- After ten days
* Breastfeeding may speed it up
What is one factor that makes the first hour after birth so dangerous for a woman?
Uterine atony and the resulting risk of hemorrhage
What is uterine atony? Why is it dangerous?
o Uterus has no tone – not contracting
o Can lead to hemorrhage: One of the top reasons women die worldwide.
Prophylactic treatment for uterine atony. What is the dose and rate?
PITOCIN:
- 1000cc with 20 units of pitocin x2
- Rate: 100 - 125cc / hr
The failure or delay of hthe uterus to return to the non-pregnant state refers to __________.
Subinvolution
What causes subinvolution?
Infection or retained placental fragments
How long do uterine contractions continue?
Through the postpartum period
What causes the development of lochia?
Blood vessels clamp down, uterine lining sloughs out, maternal blood goes with it.
What pregnancy hormones are reduced immediately postpartum? (2)
Estrogen, Progesterone
Progesterone ceases until ______
First ovulation
When does endometrial regeneration occur?
Within six weeks after delivery
What comprises lochia?
Uterine discharge of blood, waste
What are the three types of lochia?
Lochia rubra
Lochia serosa
Lochia alba
What is lochia rubra?
• Days after birth
• Color
• Composition (4)
- Days after birth: 1-3
- Color: Bright red
- Composition: Leukocytes, bacteria, white blood cells, fragments of lining
What is lochia serosa?
• Days after birth
• Color
• Composition
- Days after birth: 3-10
- Color: Pinkish brown
- Composition: Leukocytes invade the area and help heal
What is lochia alba?
• Days after birth
• Color
• Composition
- Days after birth: Day 10 or 11 to 3 weeks (can last up to 5 weeks)
- Color Pale (Amount is decreased)
- Composition: Cells, serum, leukocytes, bacteria
Bleeding: What is the first thing you do?
Massage the fundus
How does the fundus respond to massage?
If it’s soft, it will contract.
Any time you enter any patient’s room, you should assess what three things?
- Pain
- Bleeding
- IV site
Define scant lochia
<2.5 cm (1 in ch) stain
Define light lochia
2.5 - 10 cm (1-4”) stain
Define moderate lochia
10-15cm (4 to 6”) stain
Define heavy lochia
Saturated in 1 hours time
What causes pregnancy hormones to decrease?
Expulsion of placenta
Five hormones that decrease with placental expulsion
o Human Placental Lactogen (hPL) o Human chorionic gonadotropin (hCG) o Estrogen o Progesterone o Cortisol
Functions of Human placental lactogen (hPL) in pregnancy (2)
- Promotes normal nutrition and growth of the fetus
* Promotes maternal breast development and lactation
Function of human chorionic gonadotropin (hCG) in pregnancy (2)
- Helps to maintain the corpus luteum and persist for the first 6-8 weeks of pregnancy
- Helps to secrete progesterone and estrogen
Function of Estrogen in pregnancy (3)
- Breast enlargement
- Growth of breast ducts
- Enlargement of the external genitalia
Function of progesterone in pregnancy (1)
• Promotes normal continuation of pregnancy
Function of Cortisol in pregnancy (2)
- Helps with metabolism of glucose, protein, fats
* Anti-inflammatory effect that is thought to prevent rejection of pregnancy.
What is lactation?
The formation of breast milk
What stimulates the growth of milk glands?
Estrogen level produced by the placenta
What causes breasts to increase in size? (2)
- Larger glands
* Accumulated fluid
Changes in breasts postpartum
o First two days: Very little difference in a woman
o First 2-3 days: Colostrum
o 3-5 days: Breasts becomes full
Role of suckling (2)
o Causes continued release of oxytocin and prolactin
o Production of milk depends on the suckling of the infant or the use of a breast pump.
What happens to the vagina post-partum?
Rugae
How can you advise a mother to tighten her vagina?
Kegels
Changes to the cervix post-partum (timing)
o Contraction of cervix toward its pre-preganant state begins at once.
o By the end of the seventh day, external os opening narrows to the size of a pencil.
Changes in the perineum postpartum (3)
- Edema
- Bruising
- Hemorrhoids
The cervix of someone who never had a baby is known as:
Nulliparous cervix
The cervix of someone who has had a baby is known as:
Parous cervix
How does a nulliparous cervix differ from a parous cervix?
The nulliparous cervix has a round os, the parous cervix has a slit os.
For every 250 mL of blood loss (2 changes)
o Four point increase in hematocrit
o 1g decrease in hemoglobin
How much blood loss at birth is considered normal for:
- Vaginal birth
- Caesarean birth
- Vaginal birth: Up to 500 cc
* Caesarean birth: Up to 1000 cc
What happens to maternal cardiac output postpartum? What is the risk?
Increase in maternal cardiac output
**RISK: HTN
What causes increase to maternal cardiac output postpartum (4)?
o 1) Blood from the uteroplacental unit now returns to the maternal central.
o 2) Pressure on the blood vessels from gravid uterus is gone
o 3) Excess extracellular fluid returns
o 4) Also, blood vessels are constricting
o During the postpartum period, the body rids itself of excess plasma volume that was needed during pregnancy by two main routes:
o Diuresis: 3,000 cc/day
o Diaphoresis: Especially at night (2nd night: wakes up soaked)
Cardiac output postpartum (timing)
o Remains elevated for at least 48 hours postpartum
o Returns to pre-pregnancy levels within 2 weeks postpartum
Post-partum changes: Blood levels
- Hemoconcentration (due to volume loss, RBCs become more concentrated)
- Elevated WBCs (Not a concern unless there’s a source of infection)
Other postpartum changes (6)
o Increased appetite o Delayed bowel evacuation o Urinary retention o Stabilization of joints o Reverse of hyperpigmentation o Percieved Hair Loss
When should you worry about postpartum urinary retention?
Cath if mom doesn’t pee for 6-8 hours after labor
What makes a postpartum woman’s hips hurt?
Relaxin ⇒ Makes hips pliable. Sometimes painful.
What are “normal” causes of fever postpartum?
Related to dehydration and exhaustion
8 Components of postpartum nursing assessment
o Vital signs o Breasts and nipples o Abdomen o Uterus / fundus o Bladder o Perineum: Intact? Episiotomy? o Lochia o Lower extremities
If the fundus is to the _____, it is likely because _______.
If the fundus is to the right, it is likely because she has a full bladder.
Fundal assessment: Possible abnormal findings
- Fundal height greater than expected
* Fundus not firm (“boggy”)
Woman’s position for a perineal assessment
Side-lying position, bent knee
Three things to check for during a perineal assessment
- Edema
- Bruising
- Well-approximated wound margins form an episiotomy / laceration tear
What is an episiotomy?
A surgical incision of the perineum to prevent tearing and help to release pressure on the fetal head at birth
What is a laceration?
- When the woman tears on her own
* A jagged cut or tear that may involve only the skin layer or may penetrate deep subcutaneous tissues or tendons
How long does it take lacerations / repairs to heal?
2-3 weeks postpartum
A laceration affecting the _______ may cause a woman to have difficulty urinating after birth
Periurethral
Tears in the _____ may be a source of significant bleeding after birth
The Cervix
What does a 1st degree perineal tear involve?
Superficial vaginal mucosa or perineal skin
What does a second degree perineal tear involve?
Deeper tissues, may include muscles of perineum
What does a third degree perineal tear involve?
Anal sphincter
What does a third degree perineal tear involve?
Anal sphincter into rectal mucosa
Perineal care: Six items
o Mesh underwear
o Should change pad each time she goes to the bathroom
o Tucks: Hemorrhoid cream: Keep it in the fridge; put it in the fold of incision or hemorrhoid.
o Peripad (ice)
o Peripodal
o Sitz bath: Great for hemorrhoids or an episiotomy. “The poor man’s bidet.”
Plan of care / interventions (7)
o Prevention of infection
o Prevention of excess bleeding
o Promote comfort, rest, ambulation, exercise
o Promote nutrition
o Promotion of normal bowel and bladder functions
o Breast feeding promotion or lactation suppression
o Health promotion / protection of future pregnancy
Nutrition needs: Pregnancy v. Postpartum
- 500 additional calories per day to breastfeed
* 300 additional calories a day for pregnancy
Five components of postpartum psychological assessment
o Impact of birth experience o Maternal self image / sexuality o Family structure and functioning o Impact of cultural diversity o Adaptation to parenthood / parent
3 stages of maternal postpartum adjustment
- 1st phase: Dependent: “Taking it in”
- 2nd phase: Dependent-independent: “Taking hold”
- 3rd phase: Interdependent: “Letting Go”
3 stages of paternal postpartum adjustment
- Stage 1: Expectations
- Stage 2: Reality
- Stage 3: Transition to mastery
Postpartum blues
• Prevalence
• Timing
• Symptoms
- Approximately 50-80% prevalence
- Peaks by within the first week and usually resolves by the second week
- Symptoms are usually unrelated to events. Emotionally labile, Transient
Postpartum depression prevalence
15-20% of women
Signs and symptoms of postpartum depression (6)
- Worsening of sleep disturbances
- Appetite change
- Worsening depression and irritability
- Withdrawal and social isolation
- Lacks compensatory measures
- Interaction with baby is burdensome and demanding
