Exam 1: Postpartum lecture 3 Flashcards
Care/coping of the postpartum patient Assessment- BUBBLEHE Postpartum depression/blues Postpartum medications Postpartum Hemorrhage
Postpartum: what is it?
critical transitional time
-last about 6 weeks
Postpartum: Materanal physiologic Adaptations - Involution
NORMAL
the return of the uterus to a non-pregnant state after birth
- begins immediately after the placenta is delivered (decrease of estrogen+ progesterone) with contractions of the uterine muscle
Postpartum: Materanal physiologic Adaptations - SUBinvolution
ABNORMAL
The failure of the uterus to return to the non-pregnant state
-common causes are retained placental parts + infx
Postpartum: Materanal physiologic Adaptations - Lochia
NORMAL
right after delivery
-vaginal discharge lasting 4-8 weeks
-color changes result from the changing composition of the tissue expelled
Postpartum: Materanal physiologic Adaptations - Lochia Types
-Lochia rubra
-Lochia serosa
- lochia alba
Lochia: what patient should know
-color
-smell
-amount to expect
Lochia normal findings
-lochia at any stage SHOULD have a fleshy smell
-amounts that are normal: scant, light, + moderate
Lochia abnormal findings
-Offensive oder usually indicates an infx
-amount that is abnormal: Heavy amount (saturated in 1 hr)
Lochia rubra: color + lasts for how long?
NORMAL
-bright red
-lasting 1-4 days
-within hospital setting
(remember R comes before S)
Lochia serosa: color +lasts for how long?
NORMAL
-pinkish brown color
-containing old blood + serum tissue debris
-occurring AFTER rubra lasting 3-10 days
(remember R comes before S)
Lochia alba: color + lasts for how long?
NORMAL
-creamy white/light brown
-containing leukocytes + decidual tissue
-lasting 10-14 days + can last 3-6 weeks
Postpartum Maternal physiologic adaptations: Afterpains
breastfeeding + IV or IM oxytocin stimulate contractions
-for 1st time pregnancies: mom’s uterine tone is good w/mild contractions
-subsequent pregnancies (more than 1 pregnancies): more acute + uncomfortable cramping.
-more cramping when uterus has been over distended.
Postpartum Maternal physiologic adaptations: Cervix expected findings
-internal cervical os gradually closes + returns to normal BY 2 WEEKS
-external os widens + NEVER regains it pre-pregnancy appearance (it appears as a jagged slit-like opening)
Postpartum Maternal physiologic adaptations: Vagina + Perineum
-estrogen deprivation that occurs after birth is responsible for causing the thinness of the vaginal mucosa + absence rugae
Postpartum Maternal physiologic adaptations: Vagina normal findings
-vagina gradually decreases in size + regains tone over serval weeks (4-6w)
Postpartum Maternal physiologic adaptations: Vagina + Perineum -
teaching
water-soluble lubricate during intercourse is recommended for estrogen deficiency
-estrogen deficiency is responsible for decreased lubrication
-Pelvic floor muscle training exercises
-pelvic floor tone + promote healing
Postpartum Maternal physiologic adaptations: Perineum normal findings
-Perineum stretches + most women will have some degree of perineal trauma during childbirth
-edema + busing first few days
-Episiotomy or laceration may take as long as 4-6 weeks to heal
-Hemorrhoids d/t pushing
Postpartum Maternal physiologic adaptations: Cardiovascular normal findings
-CV system undergoes dramatic changes after birth
-blood volume increases during pregnancy + drops after birth + returns to normal within 4 weeks pp
Postpartum Maternal physiologic adaptations: Cardiovascular - Average blood loss for vaginal delivery + c/s
-vaginal delivery 300-500 ml
-c/s 500-1000 ml
*if loss more than those than it is considered hemorrhage + can become anemia (tx:iron &/or blood transfusion)
Postpartum Maternal physiologic adaptations: Urinary system normal findings
-gradual return of bladder tone + normal size + function of bladder, utters + renal pelvis
-difficulty voiding after delivery can lead to urinary retention, bladder distension, + UTI
-pp diuresis begins within 12 hrs AFTER childbirth + continues throughout the 1st week pp (such as alot of peeing + sweating)
Postpartum Maternal physiologic adaptations: vital signs normal findings
-cardiac output returns to prepregant levels by 3 months pp
-a decrease in BP is an expected change in early pp (may suggest hemorrhage or infx)
-temp of 100.4 F in 1st 24 hrs may be d/t dehydration (SHOULD be normal AFTER 24 hrs)
-RR 12-20 bpm @ rest
Postpartum Maternal physiologic adaptations: vital signs abnormal findings
-tachycardia/pulse (above 100 bpm) warrants investigation suggest hypovolemia, dehydrations, or hemorrhage
-increase BP (higher than 140/90) may indicate preEclampsia
-BP lower than 85/60 may indicate hemorrhage
-
Postpartum Maternal physiologic adaptations: coagulation normal findings
-clotting factors increase in pregnancy + remain elevated early pp
-the hyper-coagulable state combined with vessel damage during birth + immobility places women at risk for blood clots
Postpartum Maternal physiologic adaptations: musculoskeletal system normal findings
-joints stabilized within 6-8 weeks pp
- may notice permanent increase in shoe size
Postpartum Maternal physiologic adaptations: Integumentary normal findings
-straie gravidarum (stretch marks)
-profuse diaphoresis
-linea nigra (pregnancy line)
-melasma (freckles/dark spots on the face)
-hair loss is temporary
Postpartum Maternal physiologic adaptations: endocrine normal findings
- With delivery of placenta there is a rapid clearance of placenta hormones.
-Estrogen & progesterone drop quickly
-Prolactin levels increase and remain increased with lactating women.
-Estrogen levels remain low until breastfeeding frequence decreases.
-Lactating and non-lactating women differ for first ovulation and establishment of menstruation.
-Persistence of elevated serum prolactin levels in breast feeding women; suppress ovulation.
-Ovulation can occur before menstruation.
Postpartum Maternal physiologic adaptations: sexual health
-birth control
-resuming sexual activity (4-6 weeks)
-discussing sexual activity with patient + partner before discharge is important bc they may resume sexual activity before the 1st pp visit
Lactation
-After birth: fall in estrogen and progesterone triggers release of prolactin from anterior pituitary gland
-Prolactin levels are highest during the first 10 days PP/remain above baseline for duration of lactation
-Prolactin produced in response in infant suckling and emptying of breasts
-Oxytocin is essential to lactation
-Nipple is stimulated and the posterior pituitary is prompted by hypothalamus to produce oxytocin.
-Oxytocin responsible for the milk ejection reflex or let-down reflex.
Postpartum psychological adaptations: normal findings
-time of vulnerability to psychiatric disorders
-disrupts family life
-mood/anxiety disorders likely to recur at this time during pp (these meds are not safe for baby intrpartum)
-failure to address may result in tragic consequences
Postpartum coping
-Assess level of anxiety
-Assess sources of concern
-Identify unmet needs and expectations
-Assess support system of family
-Assess past coping mechanism
-Assess emotional reactions of birth
Postpartum emotional reactions: normal findings
baby blues
Postpartum emotional reactions: abnormal findings
-Postpartum depression
-Postpartum anxiety/Panic disorder
-PPD with OCD
-Postpartum Psychosis
Baby blues: common signs seen in pp moms
due to hormone changes should go away within 2 weeks*
-seen in 85% of new mothers
-sadness
-tear-fullness
-crying spells
-irritability, anxious
-mood swings
-fatigue/sleep caused by sleep deprivation
-appetite disturbance
Postpartum depression: risk factors
occurs in about 15% of time goes beyond 2 weeks*
-increase risk of PPD among teenage mothers; 50% higher thank older mothers
increased incidence with:
-hx of personal or family of mood disorder
Negative life event such as:
-loss of loved one
-poor marital support
-divorce
-financial difficulties
-thyroid disorders
Postpartum depression: common signs seen in pp moms
-Depressed mood
Functional impairment
Lack of affectionate bonding
-Changes of sleep pattern or eating pattern
-Excessive fatigue
-Psychomotor agitation
-Feelings of worthlessness
Suicidal ideation
Loss of interest in pleasurable activities
PPD: medical management (nonpharm)
-Natural course is one of gradual improvement over the six months after birth
Nonpharmacologic options
-Psychotherapy
-support groups
PPD: medical management (pharm)
Pharmacologic intervention:
- antidepressants
- anti-anxiety agents
- mood stabilizers
- antipsychotics
(pharm interventions done w/nonpharm interventions)
PP psychosis
most severe of mood disorders in PP period-psychiatric emergency
screening tools to prevent or detect it early
1-2/1000 births
-occurs 1-4 weeks after birth or up to 90 days after birth
PP psychosis: characteristics
-severely impaired ability
-agitation
-hallucinations **
-delusions**
-paranoia**
-severe mood depression
to look for: depression-sleep, energy level, + fatigue
PP assessments: VS, physical, psychosocial done when ?
done in L&D
1st hr: Q15 mins
2nd hr: Q 30 mins
done in PP
1st 24hrs after: Q4 hrs
After 24 hrs: Q8 hrs
Pain scale: nursing interventions
anything 4 or higher want to give tx
What does BUBBLE-EE stand for?
B- breasts
U- uterus
B- bladder
B- bowels
L- lochia
E-episiotomy /perineum/ epidural site
—–
E- extremities
E- emotional status
What does BUBBLE-EE used for?
Focus assessment for pp patient
Breast assessment normal findings
for breastfeeding moms only
nipple status
-erect nipples for good lactation + easy for baby to attach to
Breast assessment abnormal findings
abnormal nipple status
-nipples are flat or inverted (call for lactation consult)
-any redness, cracks, soreness (give cream)
Uterus assessment normal findings
important check for hemorrhage or lacerations
normal
-firm uterus
-1st hr fundus is firm @ the umbilicus
-FF @ U
FF -1
FF-2
Uterus assessment abnormal findings
abnormal
-not firm uterus is called Boggy or uterine acne (massage fundus to firm it)
-uterus is going up to the right side, high up d/t full bladder (encourage mom to use restroom)
-FF+2
FF+1
Episiotomy/Perineum/Epidural Site: assessment + nursing interventions
-roll pt on their side and look (lift cheek) to check for infx, hemorrhoids, swelling
-keep ice on 1st 24 hrs + apply cream + witch hazel or numbing spray
-still swelling after 24 hr try steam from under toilet + have them sit on seat
extremities assessemnt
mainly in calves
-no sign of blood clots d/t increase risk
-any SOB or redness/swelling on calves (call provider ASAP)
Emotional status assessment
-are they attaching w/ baby?
-screening tools for PPD
Maternal nutrition
-fluids**
-nutrient dense diet for lactating moms
500 extra calories a day
infant nutrition: who should not breastfeed?
-HIV
-PKU
-Drug abuse
prior to discharge immunizations
-rubella
-Tdap
-Influenza
- Rh status Rhogam shot (if the mom is Rh - and the baby is Rh + )
causes of PPH
-tone:uterine atony**
-trauma: laceration/rupture**
-tissue:retained placenta
-thrombin: coagulopathy (bleeding disorder)
