Exam 2: Postpartum Care Flashcards
What is the postpartum (puerperium) period?
Period after childbirth up to ~6 weeks where the PT gradually returns to pre-pregnant state
Uterine involution
Changes that occur within the uterus to return to its pre-pregnancy state
Contraction
Catabolism
Regeneration
Fundus assessment
Assess uterine tone. fundal height, uterine placement, and uterine consistency at least every 8 hours after recovery period has ended
1 hour after delivery the fundus should rise to the level of the umbilicus
Every 24 hours the fundus should descend approx. 1-2 cm
Fundus should be firm, not boggy
Lochia
Post-birth uterine discharge (blood, mucus, uterine tissue)
Amount is similar to a heavy menstrual period about 2 hours after delivery then decreases gradually and consistently
Three stages of Lochia
Lochia rubra: Dark red, bloody consistency. Fleshy odor, can contain small clots. 1-3 days after delivery
Lochia serosa: Pinkish brown and serosanguineous consistency. Can contain small clots and leukocytes. 4-10 days after delivery
Lochia alba: Yellowish white creamy color, fleshy odor. Can consist of mucus and leukocytes. 10 days -8 weeks after delivery
What must you always do when assessing the fundus?
Support the lower uterine segment
Cardiovascular system
Decrease in blood/fluid volume
Gradual decrease in cardiac output
Lower pulse rate common, hemorrhage
Blood pressure returns to pre-pregnant levels by 6 weeks
Increased coagulation factors puts PTs at risk for DVT
Urinary system
Diuresis = rapid bladder filling
Difficulty voiding
Swelling/bruised perineum, lacerations
Decreased bladder tone
Parental role attainment phases
Taking in
Taking hold
Letting go
What is the difference between attachment and bonding?
Attachment takes place overtime and is mutually satisfying
Bonding is the initial, undirectional attraction
What are the goals of postpartum care?
Promote comfort
Promote effective coping
Encourage bonding
Relieve pain
Promote healing
Education
What education topics are important for new parents?
Care at home
Care of the infant
Follow up visits
Immunizations
Birth control
How often should vital signs be taken in the postpartum period?
Q15 minutes (1st hour)
Q30 minutes (2nd hour)
Q4 hours (1st 24 hours)
Q8 hours thereafter
BUBBLEHE Focused Postpartum Physical Assessment
Breasts
Uterus
Bowel
Bladder
Lochia
Episiotomy/edema
Homan’s
Emotional status/extremities (DVT)
REEDA Incision Assessment
Redness
Edema
Ecchymosis
Discharge, Drainage
Approximation
Measures to promote comfort
Ice to perineum for 1st 24 hours (on and off 20 minutes)
Sitz bath after 24 hours
PRN local medications for perineum
Avoid what for 4 weeks after rubella immunization?
Pregnancy
Rh(d) immune globulin
Given to PT who is Rh negative and has a newborn who is Rh positive
Factors influencing attachment
Family background
Care practices
Policies discouraging exploring infant
Infant temperament and health at birth
Separation immediately after birth
Intensive care environment
Staff indifference or lack of support for family
Cultural adaptations
Rest, seclusion, dietary restraints, ceremonies
Adjustment of couple
Adaptation of siblings, grandparents
Conduct a cultural assessment accomplished through conversation with new family
Supporting a patient’s choice: Lactation
Initiate as soon as newborn is dried, assessed, and stable
Exclusive chest feeding for 1st 6 months
Should be continued for 1st year and beyond
Supporting a patient’s choice: Bottle feeding - Suppression
Milk will come in 2-4 even if not chest feeding
Engorgement will resolve
Ice/tight bra
Acetaminophen for discomfort
No stimulation of breasts/nipples
Engorgement causes
Infrequent feeding
Incomplete emptying
Non-chest feeding mother
Engorgement symptoms
Hard and tender
Swollen and inflamed
Difficult for infant to grasp
Engorgement treatment
Encourage feeding every 2-4 hours
Apply warm compress before feed
Cold compress after to reduce swelling
Express small amount of milk to soften and promote lactation
Feed on affected side first
Check for proper nipple placement
Chest massage
Ultrasound
Pumping
Anti-inflammatories
Cabbage leaf compress
Maintain milk supply!
Cracked nipples
Cracked, blistered, fissures, bleeding
Improper positioning and latch
Assessment: Are they soft, filling, engorged?
May need lactation consultant
Analgesics for pain
Lift infant’s head, face nipple directly
Lactation suppression treatment
Tight supportive bra around the clock
Ice for 15-20 minutes ever other hour
Avoid sexual stimulation
Do not squeeze or manually suppress
Avoid warmth (face away in shower)
Cabbage leaves in bras
Postpartum danger signs
Fever greater than 100.4 after 1st 24 hours
Foul smelling lochia
Change in color or amount of lochia
Large blood clots
Saturated pad in 1 hour
Severe headache
Visual changes
Calf pain with dorsiflexion
Swelling, redness, discharge at incision site
Dysuria, burning, incomplete emptying of bladder
Shortness of breath or dyspnea with exertion
Depression or extreme mood swings
What is Mastitis
Inflammation of chest connective tissue
Plugged duct going unnoticed
Cracks in nipple providing pathway for pathogens
Tissue trauma
Symptoms of mastitis
Red, hot, hard, tender to touch
Produces fever/flu-like symptoms
Localized outside of duct
Mastitis is a result of
Parental fatigue, overextended
Chest not emptying
Abrupt weaning or changes in feeding patterns
Management of mastitis
Lactation consultant
Warm soaks and massage area
Antibiotic therapy
Analgesics/NSAIDs,
Rest, fluids, proper nutrition
Empty chest and CONTINUE TO NURSE ON AFFECTED SIDE
Reassurance
Practice cleanliness
What is postpartum hemorrhage
Early or late onset
Life threatening
Leading cause of pregnancy mortality
Most within 4 hours of birth
Risk factors of postpartum hemorrhage
C-section
Operative vaginal delivery
Precipitous labor
Atypically attached placenta
Retained placenta fragments
Fetal demise
Anesthesia
Previous history of PPH
Multiparity (more than 5 pregnancies)
Multiple gestations
Placenta previa
Pathophysiology of postpartum hemorrhage
Excessive bleeding
More than 500 ml vaginal birth and 1000 ml c-section
Causes:
Tone (uterine atony = early)
Tissue
Trauma
Thrombin
Traction
What is subinvolution?
Failure for uterus to go back to pre-pregnancy state often caused by placental fragments
May occur without warning 1-6 weeks postpartum
What is uterine atony?
Most commonly within first hour of birth
Overdistention of uterus
Uterine anomaly
Assessment findings: Excessive bleeding, boggy fundus
Nursing management of postpartum hemorrhage
Identify and correct the source
Massage the fundus if uterine atony
Administer uterotonic meds: Oxytocin, Cytotec (rectally), Methergine (cannot give if BP elevated in labor), Hemabate.
Assess quantity and quality of bleeding
Frequent VS and fundal height assessment
Determine if placental fragments and prepare for D&C if late onset subinvolution
Assess signs of hypovolemic shock
Bleeding protocol
Methergine
Used postpartum to sustain uterine contractions promoting involution and preventing/controlling PPH
Should NOT be used to induce labor
Contraindicated for hypertension or preeclampsia
Cytotec
Prevent peptic ulcers, off-label effective in controlling uterine bleeding
Given rectally
Contraindicated for hypersensitivity to prostaglandins or additives in gel or suppository
Postpartum infection
Puerperal infection: Fever of 100.4+ occurring on at least 2 days within first 10 days post childbirth (excludes first 24 hours)
Risk factors:
C-section or operative vaginal birth
Prolonged labor or prolonged rupture of membranes
Chorioamnionitis
Vaginal/perineal lacerations
Postpartum hemorrhage
Retained placental fragments
Diabetes
Compromised health status
Endometritis (metritis)
Infection of uterine lining
Can extend to ovaries, fallopian tubes, pelvic thrombophlebitis
Wound infections
C-section incision site
Episiotomy
Perineal or genital tract laceration
UTI
Catheterization
Trauma from delivery
Nursing management of infections
Administer broad-spectrum IV antibiotics
Manage pain
Monitor for possible complications or worsening of condition
PT education: S/S worsening condition, compliance with therapy, self care, follow up care
