Chapter 17: Postpartum Physical Adjustment Flashcards
1
Q
what is the puerperium?
A
- it is the first 6 weeks following births
- sometimes called the “fourth trimester”
- woman experiences physical and psychosocial changes
- nurses role: assess the patient, implement care, teach the new family
2
Q
what is involution of the uterus?
A
- process of the uterus returning to its non-pregnant size and condition
3
Q
what are the 3 processes involved with uterine involution?
A
- contraction of muscle fibers: uterine involution begins immediately after birth when uterine muscle fibers contract around blood vessels
- decreases size of uterus
- controls bleeding
- catabolism: muscle cells of uterus shrink in size
- byproducts are excreted in the urine–allows woman to get rid of extra fluid
- regeneration of uterine epithelium
- begins after childbirth
- first layer of decidua shed in lochia
- basal layer of decidua is source of new endometrium
- regeneration of new endometrium occurs w/in 2-3 weeks except at site of placental attachment
- healing at placental site takes place in 6 weeks
4
Q
what is a risk of getting pregnant during the period prior to the uterine epithelium completely healing?
A
placenta previa–b/c the placental attachment site is not healed before 6 weeks postpartum, so a new fetus cannot implant in the posterior fundus if it is not completely healed
5
Q
how to determine descent of uterine fundus
A
- Location of uterine fundus helps determine whether involution is occurring
- Immediately after birth: fundus palpated halfway b/w pubic symphysis and umbilicus in midline of abdomen
- w/in 12 hours: fundus rises to approximately the level of umbilicus
- Fundus descends by approx 1 cm per day
- By 14th day, it has descended into pelvic cavity and cannot be palpated
6
Q
factors that enhance uterine involution
A
- uncomplicated labor and delivery
- breastfeeding: stimulate oxytocin release–>cause uterine contraction
- early ambulation
- complete expulsion of placenta and membranes
7
Q
what are factors that slow descent of the uterine fundus?
A
- more than one fetus
- large fetus
- hydramnios
8
Q
what are factors that slow uterine involution?
A
- prolonged labor or difficult delivery
- anesthesia
- grand multiparity: b/c uterus is overdistended and doesn’t contract like it should
- retained placental fragments
- infection
- overdistention of the uterus: can be due to polyhydramnios
- full urinary bladder
9
Q
what is subinvolution? what does it increase risk of? what are the most common causes?
A
- subinvolution is a slower than expected return of the uterus to its nonpregnant size
- can cause postpartum hemorrhage
- most common causes:
- retained placental fragments
- pelvic infection
10
Q
what are the S/S of subinvolution?
A
- Prolonged discharge of lochia
- Irregular or excessive uterine bleeding
- Profuse hemorrhage
- Pelvic pain or feelings of pelvic heaviness
- Backache
- Fatigue
- Persistent malaise
- Uterus feels larger and softer
11
Q
subinvolution: treatment
A
- Methylergonovine: given PO
- Provides long, sustained uterine contraction
- Infection responds to antimicrobial treatment
12
Q
subinvolution: nursing considerations
A
- Teach mom how to recognize subinvolution
- Demonstrate how to locate and palpate the fundus and estimate the fundal height in relation to the umbilicus
- Explain the progressive changes of lochia
- Instruct the mother to report any deviation from expected pattern or duration of lochia
- Report any signs of foul odor, pelvic/fundal pain, backache, feelings of pelvic pressure or fullness
13
Q
what are afterpains? what makes afterpains worse? what are nursing considerations for afterpains?
A
- Afterpains are intermittent uterine contractions
- More acute for multiparas b/c repeated stretching leads to loss of muscle tone
- Made worse by breastfeeding b/c oxytocin released from the posterior pituitary stimulates the milk ejection reflex and causes strong contractions of the uterus
- Nursing considerations:
- Analgesics are common
- Sometimes helps to lie in a prone position with a small pillow or folded blanket under the abdomen to keep the uterus contracted
- Can tell woman that they are self-limiting and will subside by 3rd day
14
Q
lochia rubra
A
- days 1-3
- normal: bloody, small clots, fleshy/earthy odor, dark red or red brown
- abnormal: large clots, saturated perineal pads, foul odor
15
Q
lochia serosa
A
- days 3-10
- normal: decreased amount, serosanguinous, pink or brown tinged
- abnormal: excessive amount, foul smell, continued or recurrent reddish color
16
Q
lochia alba
A
- days 10-14
- normal: white, cream, or light yellow color; decreasing amounts
- abnormal: persistent lochia serosa, return to lochia rubra, foul odor, discharge continuing
17
Q
what is a concerning sign with lochia? what does it signify?
A
- concerned if pt progresses to alba then all the sudden goes back to rubra
- usually signifies infection
18
Q
would vaginal or C/S delivery have more lochia? why?
A
- vaginal deliveries would result in more lochia
- b/c in C/S: they clean out the uterus and get a lot of that out
19
Q
how to measure lochia
A
- Measure for one hour:
- Scant: less than a 1 in stain on peripad
- Light: less than a 4 in stain on pad
- Moderate: less than a 6 in stain on pad
- Heavy: saturated peripad in 1 hour
- Excessive: saturated peripad in 15 min
- Sometimes bleeding can suddenly inc at 7-14 days postpartum due to the eschar over the placental site sloughing off
- But if lasts longer than 1-2 hours, then call HCP
20
Q
postpartum cervix
A
- after birth, the cervix is dilated, edematous and bruised
- may have small tears or lacerations
- external os heals rapidly and is 1 cm by end of first week
- but the shape is forever changed to slit-like appearance rather than round, dimple like os of nullipara
- internal os returns to pre-pregnancy state
21
Q
postpartum vagina
A
- smooth walls due to lack of rugae
- rugae begin to reappear by 3-4 weeks
- edematous and has lacerations
- may be an area of hematoma formation which the woman describes as “pressure” pain and is unrelieved by medications
- During postpartum, vaginal mucosa atrophies and the vaginal walls do not regain thickness until estrogen production by the ovaries is reestablished
- While breastfeeding, estrogen production is not well established, so vaginal dryness and dyspareunia are common
22
Q
what does it mean if there is inc lochia with a firm uterine fundus?
A
significant lacerations
23
Q
postpartum perineum
A
- may be edematous and bruised
- episiotomy takes 2-3 weeks to start to heal, but may take up to 4-6 mos to completely heal
- discomfort very common b/c muscles of perineum involved in everyday activities
- hemorrhoids are common
- elimination may be difficult due to inc constipation after birth with an inc risk due to opioids
24
Q
nursing care for postpartum perineal discomfort
A
- clients should be free from perineal pain w/in 2 weeks
- relief of discomfort is a nursing priority:
- apply ice (first 24 hours)
- sitz baths (after 24 hours)
- topical anesthetics and analgesics
- perineal care
25
postpartum cardiovascular system
* inc in pregnancy
* plasma volume: returns to pre-pregnant state w/in 2 weeks
* these are all methods that the body uses to get rid of extra fluid:
* post partal diuresis (12 hours-5 days postpartum)
* diaphoresis (hot flashes common)
* coagulation (elevation of fibrinogen--up to 1 wk)
* blood values: H&H (anemia or blood loss evaluation); WBCs (non-pathologic if inc up to 25-30000)
* bradycardia (50-70 bpm)
26
aldosterone after pregnancy
* inc during pregnancy
* decreases after pregnancy which allows new mom to drop off all the extra fluid through urination
27
at what HR are we concerned about a postpartum mom? why?
* concerned if HR is over 100 b/c it can indicate a postpartum hemorrhage
28
postpartum GI system
* hunger and thirst are common
* risk for constipation inc b/c of dec peristalsis and bowel tone from pregnancy, use of narcotics, dec mobility during labor, and fear of painful bowel movements
* always administer stool softeners, and first stool is usually w/in 2-3 days postpartum
* normal bowel elimination w/in 1-2 weeks
* pushing inc risk of hemorrhoids
29
postpartum GU system
* inc bladder capacity and less awareness of bladder fullness can lead to incomplete emptying and excess residual volume
* stress incontinence occurs in many in the first 6 weeks
* prone to this b/c of trauma and stretching to perineal area
* Kegal exercises help inc muscle tone
30
urinary retention postpartum
* more common: after 1st vaginal delivery, regional anesthesia, and catheterization before delivery
* complications: UTI, inc postpartum bleeding b/c of stretched uterine ligaments which allow uterus to be displaced upward and laterally which results in dec contraction of uterine Ms--\>bleeding
* inc risk for urinary retention b/c the bladder is less sensitive to fluid pressure, decreasing the urge to void even when bladder is distended
31
postpartum musculoskeletal system
* Muscle fatigue and aches occur in first 1-2 days after childbirth
* Warmth and massage help with this
* Hip and joint pain occur b/c the hormone relaxin dec in concentration and ligaments of the pelvis return to pre-pregnancy positions
* Help mom to use good body mechanics and correct posture
* Abdominal muscle tone is diminished after pregnancy
* Diastasis recti: may occur--longitudinal muscles of the abdomen may separate
32
postpartum integumentary system
* skin is soft and flabby with dec muscle tone
* ruptured elastic fibers in the skin cause striae which are red during pregnancy but will fade to silver/white
* estrogen, progesterone, and melanocyte stimulating Hs decline after childbirth, and melasma and linea nigra fade and disappear
33
postpartum neurologic system
* discomfort and fatigue are common
* analgesia and anesthesia may cause temporary neurologic changes such as a lack of feeling and dizziness
* prevention of injury is PRIORITY
* HAs must be assessed
34
postpartum HAs
* Frontal and bilateral: common in 1st week postpartum and may be a result of changes in fluids/electrolytes
* Severe HA: postdural puncture HA--from regional anesthesia
* Most severe when woman is upright
* HA w/ blurred vision, photophobia, proteinuria, and abdominal pain: may indicate development or worsening of pre-eclampsia
* in the frontal are, not relieved by analgesics, and does not change with position changes
35
resumption of ovulation and menstruation for bottle feeding women
* menses returns w/in 6-8 weeks for 40% of women and 12 weeks for 75% of women, the rest of women have it return by 6 months
* usually _takes about 2 months_
36
resumption of ovulation and menstruation for breast feeding women
* delays the return of ovulation and menstruation, but it is not predictable so contraception is important!
* menses may return as early as 12 weeks or as late as 18 months during menstruation
* If you breastfeed more often and use fewer supplements, likely to ovulate and menstruate later
37
lactation
* During pregnancy, estrogen and progesterone prepare breasts for lactation
* Prolactin also rises during pregnancy, but lactation inhibited at this time b/c estrogen and progesterone are so high
* When placenta delivered, estrogen and progesterone drop and prolactin initiates milk production in 2-3 days
* Once milk production is established, it continues b/c of frequent suckling by infant and removal of milk from the breast
* Oxytocin: necessary for milk ejection or “let down”
38
postpartum thyroid
* thyroid levels return to normal in 4-6 weeks but there is a risk of transient autoimmune thyroiditis and hypothyroidism
39
weight loss after childbirth
* Childbirth: Lose 4.5-5.8 kg (10-13 lb)
* Diuresis: lose 2.3-3.6 (5-8 lb)
* Involution and lochia: lose 0.9-1.4 kg (2-3 lb)
* Total loss first week: 17-24 lbs
* Continues especially during the first 3 months
* Most likely to lose all but about 1 kg (2.2 lb) w/in 1 year if follow a well balanced diet
40
post partum physical adaptations: temp, BP, HR
* temp: expected temp elevation due to dehydration, epidural anesthesia, or breast engorgement
* morbid temperature elevation over 100.4 deg F could indicate infection
* BP:
* orthostatic hypoTN: fall precautions
* decrease may also be due to dehydration or hypovolemia
* elevations: possible pregnancy induced HTN (PIH)
* if over 140/90: may indicate pre-eclampsia
* pulse:
* bradycardia: acceptable first 6-10 days
* tachycardia: over 100+ could be hemorrhage or infection
41
REEDA Scale
* used when looking at incisions, lacerations
* R: redness
* E: edema
* E: ecchymosis
* D: discharge
* A: approximation
42
assessment of the postpartum woman
* BUBBLE-HE
* **B**: Breast
* assess stage of lactation, nipples
* **U**: Uterus
* **B**: Bladder
* **B**: Bowel
* **L**: Lochia
* **E**: edema
* **H**: Homan's sign, hemorrhage
* **E**: emotions
43
comfort measures and analgesics to use in the immediate postpartum period
* comfort measures:
* ice packs
* perineal care: peribottle, pat dry but don't wipe
* topical meds: tucks, dermoplast
* instruction on sitting: clamp buttocks as sitting to put less pressure on stitches
* sitz baths
* analgesics:
* NSAID: ibuprofen 600 mg Q6h
* acetaminophen
* narcotics: percocet (oxycodone w/ acetaminophen 5/325)
44
rubella vaccine
* woman receives rubella antibody screen during prenatal period
* If she is not immune, she is given rubella vaccine to prevent her from acquiring rubella during subsequent pregnancies
* Should not become pregnant for 28 days after receiving vaccine
* refridgerate
45
pertussis vaccine
* all adults in contact with infants should get a booster shot
* Vaccine may be offered during pregnancy or before discharge and is usually given with Tdap
46
RhoGAM
* needed if mother is Rh neg, baby is Rh pos, and mother is NOT already sensitized (by a previous Rh + baby or previous RhoGAM)
* give w/in 72 hours to prevent Ab
* comes from blood bank
* IM, possible fever and pain at site
* blood consent
47
risk factors for hemorrhage
* Grand multiparity (5 or more),
* overdistention of uterus,
* precipitous labor (less than 3 hours),
* prolonged labor,
* retained placenta,
* placenta previa,
* drugs,
* operative procedures
48
risk factors for infection
* Operative procedures,
* multiple cervical exams,
* prolonged labor,
* prolonged ROM,
* manual extraction of placenta,
* diabetes,
* catheterization,
* bacterial colonization of lower genital tract
49
what are signs of an empty bladder?
* firm fundus in midline
* nonpalpable bladder
* mother voiding at least 300-400 mL
50
what are signs of bladder distention?
* obvious or palpable bulge that feels like a soft, moveable mass above the symphysis pubis
* Also will see upward and lateral displacement of the uterine fundus and inc lochia
51
when to catheterize a woman?
* She is unable to void
* Amount voided is less than 150 mL and bladder can be palpated
* Fundus is elevated or displaced from midline
52
how long does a woman usually stay in the hospital if she had a C/S?
72-96 hours
53
respiratory assessment after a C/S
* Must assess frequently if mother is given narcotics
* Pulse ox is used for 18-24 hours--\>should be documented hourly
* If woman has a RR of 12 or less or pulse ox shows persistent O2 sats of less than 95%, then:
* Notify anesthesiologist
* Elevate head of bed and instruct woman to breathe deeply
* Administer O2
* Administer narcotic antagonists
* Observe for recurrence of respiratory depression b/c of duration of naloxone being only 30 min
* Recognize that naloxone may reduce level of pain relief
54
interventions for the first 24 hours after a C/S
* pain relief: determine need for pain relief on regular basis
* PCA, duramorpha
* relaxation: breathing techniques
* ambulation:
* help woman sit and dangle feet first
* encourage her to do active ROM exercises
* prevent secretions from pooling by turning, coughing, deep breathing, and using IS to expand lungs and prevent pneumonia
* IV: replenish fluids
* hydration: ice chips then clear fluids
* foley: observe I/O
* abdomen: check dressing, observe incision, check bowel sounds (may be hypoactive)
* DVT prevention: sequentials
* infant feeding: much assistance
55
interventions after first 24 hours for C/S
* pain relief: oral pain meds
* ambulation: encourage walking
* diet: soft or regular diet when bowel sounds are audible
* hydration: encourage fluids
* IV: discontinue
* foley: remove
* abdomen: check dressing, check bowel sounds (should be normal and passing gas)
* infant feeding: less help needed
56
preventing abdominal distention after C/S
* Early, frequent ambulation
* Tighten and relax abdominal muscle
* Avoid carbonated beverages and use of straws
* Pelvic lifts
* Simethicone: to disperse upper GI flatulence
* Rectal suppositories: to stimulate peristalsis
57
breast care if lactating
* Instruct mom to avoid using soap on nipples b/c it will remove natural lubricant
* Keep nipple dry between feedings to prevent tissue damage
* Wear a good bra to provide support
58
breast care to suppress lactation
* Wear a sports bra or well fitting bra 24 hours a day until the breasts become soft
* Manage breast discomfort with ice and analgesics
* Allow woman to avoid warm water falling directly onto breasts which stimulates milk production
59
sexual activity
* May begin intercourse as early as 2 weeks after giving birth if desire and comfort allow
* Low estrogen levels during early postpartum period and during lactation may cause vaginal dryness, so may need water based lube
60
follow up appointments
* Vaginal birth: 4-6 weeks
* Cesarean birth: 2 weeks
61
warning signs to report
* Fever over 100.4 def F
* Localized area of redness, swelling, or pain in either breast
* Persistent abdominal tenderness
* Feelings of pelvic fullness or pelvic pressure
* Persistent perineal pain
* Frequency, urgency, or burning or urination
* Abnormal change in character of lochia
* lochia alba/serosa back to rubra
* odor
* Localized tenderness, redness, edema, or warmth of the legs
* redness separation or edema of, or foul drainage from incision
