Class 8 postpartum Flashcards
what are the goals of postpartum stay?
-help transition to home
- support care for birther/parent(s) and newborn
How long does Postpartum last?
6-12 weeks
how long does someone with a non-complicated vaginal delivery stay in hospital?
24-48 hours
how long does someone with c-section stay in hospital usually?
4 days
what do we assess for in 4th stage? (BUBBLLEE)
B-breasts
U- uterine fundus/uterotonics
B- Bowels
B- Bladder
L- Lochia
L- Legs
E- episiotomy/lacerations
E- emotional
how often do we check vitals after delivary?
BP, HR, RR
q15 min x4
q30 min x2
Temp: x1 and prn
how often do we check the fundus after birth?
Q15 min x4
q30 min x2
Why do we want birthers to empty their bladder?
prevent bleeding
What meds are usually given post delivery for pain ?
Acetaminophen and NSAIDS
what vaccination do we want to ensure birthers have before disharge?
Rubella
When is WINRHO indicated?
If the birther is Rh negative
AND
the infant is Rh positive
What should breasts be like 1-2 days post delivery?
soft - regular feedings
What should breasts be like days 2-3 post delivery?
filling
-can use warm cloths/icepacks between feedings
What should breasts be like 3-5 days post delivery?
full & soft with feeding
- can give lanolin to prevent cracks, blistering/abraisons
What are some abnormal signs in nipples?
cracks
soreness
blistering
abrasions
how how many hours should a baby be fed?
2-3 hours min
and PRN (signs of hunger)
What should the shape of the Uterus be PP?
round like a grapefruit
Where should uterus be PP?
midline on abdomen
height at umbilicus
What kind of uterus do we not want?
a boggy one
what are the 3 interventions we can do for normal after pains of the uterus?
acetaminophen
NSAIDS
heat packs
What does it mean if the uterus is too high up (past the ubilicus)?
not contracting properly
If the uterus is off to one side what does that indicate?
likely need to empty the bladder
how long does it take to no longer palpate the uterus?
after 2 weeks
When might the uterus rise 1 cm above the umbilicus?
12 hours post birth
For uterine fundal assessment where does the nurse place their hands?
one hand on top of the uterus
the other hand over the symphysis pubis
What are the 4 steps of a uterine fundal massage?
- patient supine, knees flexed, feet together
- one hand on top of fundus, other hand above pubis symphsis
- Massage: rotate upper hand to massage uterus until firm
- Expel blood clots: downward pressure
What is our FIRST intervention with a boggy uterus/too high above the umbilicus?
FUNDAL MASSAGE!
When should someone be able to void PP and what is minimum amount?
within 8 hours
250ml
What 2 Gu things are not normal PP?
Dysuria (after 8 hours)
distension
How many days after birth is it normal to pass large amounts of urine?
2-5 days after birth
What do we not want someone to have while voiding?
pain
difficulty
dysuria
fever
When should someone hav a BM PP?
by day 2 or 3
When is it a good time to use stool softeners/laxatives?
early PP period
after extensive perineal repair
What is Lochia?
the stuff that comes out post partum
What do we assess for with Lochia?
colour
amount
odour
clots
how do we measure blood loss accurately?
Hbg or Hct
weight of perineal pad & clots
(1g=1ml of blood)
When should someone contact the HCP?
If lochia is heavier or has a bad odour
What colour can lochia be at day 1-3 ish?
Lochia Rubra: Dark red
What colour can lochia be day 3-10 (or up to 2 -4 weeks)?
Lochia Serosa - pink/brownish red
What colour can lochia be from day 10 to 4-8 weeks?
Yellowish white
how much bleeding is too much?
saturating a peripad in an hour is too much
large clots - bigger than a loonie
Go to triage
What is a normal amount of lochia blood loss?
scant to moderate - with a few small clots
What is a large amount of Lochia blood loss and what could it mean?
filling a whole pad in 1 hour
- uterine atony
-cervical/vaginal lacerations that needs repairs
What is Excessive bleeding PP?
- perineal pad that is saturated in 15 min
- pooling under the buttocks
What are we concerned with for the patients legs PP?
DVT (VTE)
What is normal to see in legs PP?
a small amount of bilateral edema
What does a normal episiotomy look like?
minimal edema
intact
Dry drsg
edges well approximated
how long does the C-section dressing stay on for?
24 hours - then inspect
What is first degree laceration?
involves:
skin
structures superficial to muscles
What is a 2nd degree laceration?
involves:
extends through muscle
What is thirds degree laceration?
invovled:
extends through the anal sphincter
what is a 4th degree laceration?
involves:
anterior rectal wall
what are the 4 things someone can do with an episotomy/laceration?
ice packs
tub bath/sitz bath
analgesics
side-lying
When can someone who had C-section shower?
after the drsg is removed 24-48 hours after
- uncovered promotes healing
Regarding a birthers emotional state what would they normally feel regarding care, sleep, and mood?
Care: for self and infant
Sleep: not restless
mood: excited, happy, interested/invovled in infant care
regarding emotional status what should we always ask birthers and why?
“how was your delivery?”
because they may have experienced trauma and it could lead to ptsd if they don’t have an outlet
What vaccine do we give PP if they are not vacinated?
Rubella (MMR)
When do we not give a vaccine?
if the person is immunocompromised
How soon can someone resume intercourse PP?
2-4 weeks (we prefer 6 weeks)
as is comfortable & no bleeding & fully healed
What are some main requirements for discharge?
-both birther & baby stable
-baseline mobility
- adequate pain control
- GU/GI adequate
- can recognize hunger cues and effectively feed baby
When does baby need their first check up?
2 weeks
-earlier if had jaundice
When should the birther have their first follow up?
6 weeks
What are the 4 complicated PP issues that put the birther at risk?
- hemorrhage
- infection
- thromboembolic conditions (DIC)
- Emotional disorders
What is a PP hemorrahage?
ANY blood loss that has the potential to cause hemodynamic instability
What is considered a late/secondary PPH?
usually at home
between 24hrs and 12 weeks post partum
What is the leading cause of PP mortality world wide?
PPH
How do we prevent PPH?
in 3rd stage labour we:
1. give oxytocin post delivery- especially anterior shoulder birth
2. fundal massage
3. gentle cord contraction
4. Uterotonics
5. inspect placenta
6. prevent full bladder
7. observe birther closely
What are the 4 Ts?
- Tone - uterine atony
- Tissue- placenta
- Trauma - uterine & tears & lacerations
- Thrombin - can’t coagulate
What are the first 2 things we do if someone is boggy?
- Fundal massage
- figure out which of the 4 Ts
What is the most common cause of Tissue issues?
retained placenta
Which of the 4 Ts is the leading cause of PPH?
Tone issues
Why can a long labour or an oxytocin induced labour cause tone issues = PPH?
because the uterus gets tired and stops wanting to contract properly
What bloodwork do we care about with uterine atony management?
CBC
T&S
antibody screen
coag study
HGB
platelets
What do we use uterotonics for?
manage and prevent PPH
What is the MOA of uterotonics?
encourage uterus to clamp down on open blood vessels at the open placental site
What is a first line uterotonic?
Oxytocin - not many side effects
What are the 3 second line uterotonics?
- Misoprostal
- Ergotamine (IM)
- Carboprost (IM)
Who should not get Ergotamine?
Those with HTN
Who should not get carboprost?
-people with asthma (bronchospasm)
-people with tears without epidural (due to explosive diarrhea)
What are two negative side effects of misoprostol?
- can cause febrile
- can cause heart issues if given too fast (bolus)
What does a Bakri balloon do and how long does it stay in?
reduces postpartum bleeding
stays in 12-14 hours
What are the Obstetrical emergencies?
- PPH
- Uterine Inversion
What is the obstetrical emergency Uterine Inversion?
uterus turns inside out
What are the 3 uterine inversions?
Incomplete- can’t see it
complete- protrudes through cervical OS
Prolapse- outside
What causes Uterine inversion?
- placenta impants wrong
- too much pressure on fundus
- pull too hard on the cord
- Tocolysis (to reduce contractions)
- Fetal macrosomia
- Uterine atony - boggys not firm
- placental tissue implants too hard into uterine wall
What do we do for Uterine Inversion management?
- AVOID aggressive fundal massage!
- 18G IV
- Fluid resus
- tocolytics then put it back
- then uterotonics
- antibiotics
when we think of the 4 Ts, what does Tissue always refer to?
Placenta (placenta issues)
What are the 4 risk factors for tissue issues = PPH?
- retained placenta fragments
- Placenta accrete, increta, percreta
- Placental abruption
- Placental previa
What is succenturiate lobe?
additional placental lobes that get stuck
What is placenta accrete syndrome?
How deep the placenta is in the uterus
How do we manage retained placenta?
*Empty bladder
Manual removal of placenta
Uterotonic meds
blood components
Frequent VS
Pain control
18 G
Tocolytics
What does Trauma refer to in the 4 Ts?
- Lacerations
- Pelvic hematomas
- Uterine rupture
- Inversion of the uterus
- manual removal of placenta
- trauma like vacuums & forceps
When do we suspect there’s trauma d/t laceration?
- bleeding keeps going even though the uterus is firm
- Perineal laceration 1st, 2nd, 3rd, 4th degree - common
- episiotomies can extend to 3rd or 4th degree
When is bleeding less concerning?
Intermittent or dark red
- likely just pooling
Which T should we assess for first?
Tone
then if not that, move to the others
What causes the most bleeding?
cervical tear
How do we manage laceration?
IV PRN
Pain management
Repair
Labs PRN
What is a pelvic hematoma?
collection of blood in the connective tissue
What are the 3 types of pelvic hematomas?
- Vulvar
- Vaginal
- Retroperitoneal
Which type of pelvic hematoma is most common?
Vulvar
What causes vaginal pelvic hematomas?
forceps
episiotomy
primagravida
Which pelvic hematoma is life threatening?
retroperiotneal
How do we differentiate between uterine atony/TONE or TRAUMA with
1. uterus
2. bleeding
3. blood presentation
Tone:
1. boggy uterus
2. intermittent bleeding
3. Dark blood & clots
Trauma:
1. firm uterus
2. continuous bleeding
3. bright red blood (arterial)
What are the 3 main Thrombin risk factors?
- Idiopathic thrombocytopenia purpura (ITP)
- von Willebrand Disease (vWD)
- Disseminated Intravasuclar coagulation (DIC)
What is Idiopathic thrombocytopenia purpura (ITP) ?
-Autoimmune disorder
- low platelets
- antibodies decrease lifespan of platelets
How do we manage ITP?
- corticosteroids/IV immuneglobulin
- Platelet transfusion
- splenectomy - to stop storage of platelets
What is Von Willebrand Disease (VWD)?
a type of hemophelia
platelets can’t stick together
bleeding from mucous membranes
heavy menses/bruise easily
What is the management of VWD?
-DDAVP - hormone to help with hemostability
-plasma transfusion
What is Disseminated Intravascular Coagulation (DIC) ?
clotting system freaks the fuck out and you get clots everywhere in the body
Too much clotting at the site of the bleed and then there’s nothing left for the rest of the body so you get bleeding
What is the main goal in DIC?
fix the root of the problem !
Fix the main bleed so it can stop over clotting that area
What are some signs of DIC?
- spontaneous bleeding
- petechiae where BP cuff was
- tachycardia
-hypotension - Diaphoresis
- Low PLT, fibrinogen, PTT
How do we manage someone with DIC?
-catheter with urometer - can cause renal failure
- O2 & perfusion
- Fluid & blood replacement
what is Tranexamic acid?
antifibrinolytic
- controls bleeding by preventing breakdown of clots
- is not a uterotonic
- given with other meds
what % of blood loss does hemorrhagic shock show in a PP patient?
may not appear until 30-40% blood loss
What is a late sign of hemorrhagic shock?
Decreased BP
What is the first thing people with hemorrhagic shock say that we need to pay attention to?
- light headed
- feel tired
- decrease U/O
how do we manage hemorrhagic shock?
- 18g IV - 2 lines
- Fluid rsuscitation
- blood administration
- labs prn
- oxygen
- I/O - cathether
What are common symptoms of a PP infection?
Fever >38 degrees
tachycardia
localized pain
up to how many days is an infection considerd post partum?
up to 42 days
what is considered a massive transfusion emergency?
4 or > units of PRBC within 1 hour and ongoing need expected
besides infection what can also cause fever in early PP?
VTE or thrombophlebitis
What are the 5 most common places for infection PP?
endometrium (endometritis)
breasts (Mastitis)
wounds
UTI
Resp inf. (PN)
What are specific S/S associated with endometritis in addition to regular infection signs?
-uterine tenderness of fundal height above expected location
- bogginess on fundal palpation
- foul-smelling lochia
What is the biggest risk factor for endometritis PP?
c-section birth
How do we know the antibiotics are working for someone with endometritis?
-fever decrease
- uterine tenderness decrease
- Lochia odor decrease
With episiotomy site or perineal tear/repair site infection when do symptoms normally tend to appear?
after discharge from the hospital
what is different about mastitis infection in terms of signs/symptoms than regular infection?
-usually localized to one breast
- flu-like
- axillary adenopathy
What are the 6 signs of sepsis
- hypotension
- tachycardia
- tachypnea
- fever
- decreased U/O
- decreased LOC
What are 2 main things to teach someone to prevent Mastitis?
- proper latch & positioning
- avoid engorgement - breast empty as possible
- Pain relief- NSAIDS, cool compress
why are we concerned about postpartum psychological complications?
- interfere with attachment
- threaten safety and well-being of family members
- impacts social/emotional development of baby/other children
What does PMD (perinatal mood disorders) emcompass?
- depression
- anxiety
- OCD
- bipolar disorder
- psychosis
which disorder is considered a psychiatric emergency?
postpartum psychosis
How do we identify perinatal depression?
intense and pervaisive sadness
severe and labile mood swings
last MORE THAN 2 WEEKS
What time frame is considered baby blues?
under 2 weeks
what time frame is considered perinatal depression?
over 2 weeks
This condition is mild, does not impair function, and resolves on its own under 2 weeks usually
PP baby blues
When do baby blues start?
day 3-4 PP
When does postpartum depression begin?
after the first 2 weeks PP
Which postpartum mental illness does not resolve on its own?
postpartum depression
This tool is used to assess postnatal depression
Edinburgh postnatal depression scale
What are the main feelings of baby blues?
- Sad, anxious, or overwhelmed feelings
- Crying spells
- Loss of appetite
- Difficulty sleeping
What are signs of postpartum psychosis?
- Seeing or hearing things that are not there
- Feelings of confusion
- Rapid mood swings
- Trying to hurt yourself or your baby
What are signs of postpartum depression?
- Same signs as baby blues, but they last longer and are more severe
- Thoughts of harming yourself or your baby
- Not having any interest in the baby
When should someone call a health care provider with postpartum blues/depression/psychosis?
- The baby blues continue for more than 2 weeks
- Symptoms of depression get worse
- Difficulty performing tasks at home or at work
- Inability to care for yourself or your baby
Contact CRISIS Services if you have: - Thoughts of harming yourself or your baby
