Exam 2 - Study Material (Postpartum) Flashcards
What is the postpartum period?
- Period after birth of neonate and up to approximately 6 weeks
- Body returns to pre-pregnant state physiologically
- Psychological adaptations as well
What is uterine involution?
- Gradual reduction of size and return of the uterus to the pre-pregnant state
- Descends about 1cm per day
- Decreases from 1000 gms after birth to 100 gm or less by PP week 6
- Size of cells decrease but not number
- Sloughing of decidua
- Exfoliation of placental site
- Autolysis-WBCs
What are some fundal changes seen during the post partum period?
- Immediately after delivery may be below the umbilicus
-
By 6-12 hours at level of umbilicus
- Involutes approx 1 cm per day postpartum
- Involutes into pelvis by 2 weeks on average
- Ligaments of uterus stretched-regain length and tension by end puerperium
- Approaches pre-pregnant size and position by 6 weeks postpartum
What are some normal characteristics of the postpartum uterus?
- Normal = firm, midline
- Pressure on blood vessels decreases bleeding
What are some abnormal characteristics of the postpartum uterus?
- Soft, boggy uterus = excessive bleeding
- Deviated from midline may = full bladder
- Continuous bleeding (without clots) and firm uterus suspect vaginal or cervical laceration
What processes may slow involution?
- Prolonged labor
- Multiparity
- Distended bladder
- Anesthesia
- Infection
- Overdistention (can be the result of multiple births, polyhydraminos, twins) Greater than 24cm
What is lochia?
It is the Sloughing of spongy outer layer of decidua and top layer of basal decidua
Odor is musty but non-offensive.
◦Malodorous = infection
What are the 3 different types of lochia?
- Rubra- Many different cells. Dark red-first 2-3days postpartum
- Serosa-pinkish-brownish 3-10 days PP. Serous exudate, decidua, RBC, WBC, etc.
- Alba- creamy white (mostly WBCs)- lasts 1-2 wks post serosa
What are some cervical changes during the postpartum period?
- Nulliparous cervix like a doughnut, os like a dot
- Parous cervical os looks like a lateral slit
- Cesarean cervix may appear nulliparous, but “pulled” anterior and upward on examination
- May need refitting of cervical cap or diaphragm
What are some vaginal changes during the postpartum period?
- Edematous and bruised after birth
- Superficial lacerations and absence of rugae
- Carunculae myrtiformes-skin tags after tearing of hymenal tissue
- Edema resolves and rugae return in 3-4 weeks
- Have them do Kegal exercises, it helps strengthn their muscles
What are some abdominal changes during postpartum?
- Abdominal wall stretched and flabby-responds to exercise 2-3 weeks
- Diastasis recti (Separation of abdominal muscles. Poor muscle tone and C/S increases risk of)
- Abdominal striae (Stretch marks)
- Sluggish bowels
What are some bladder/urinary changes during the postpartum period?
- Increased bladder capacity
- Puerperal diuresis
- Urethral swelling/bruising
- Decreased sensitivity to fluid pressure/bladder filling (pressure on uterus)
- Ureters and kidney pelves dilated
- Oxytocin has an antidiuretic effect
What are some changes to the breasts during the postpartum period?
- Considered the “final stage” of breast growth in lifetime
- Proliferation of ductal and mammary tissue
- Areolas are darker and larger
- Venous patterning on the breasts and chest are normal
- Colostrum present during pregnancy
- Drop in progesterone and estrogen signals the anterior pituitary to secrete prolactin (produces milk)
- Oxytocin releases milk
What happens during the colostral phase?
Endocrine function and lasts up to 72-96 hours, it is a phase where the breasts secrete this white substance known as colustrom (it is proteins, fats, and IgG)
What is preclampsia?
- It is a disorder of pregnancy characterized by high BP and large amounts of protein in the urine
- BP = 140/90
- Protein urea
What are some vital sign changes during the postpartum period?
- Bradycardia can occur for first 6-10 days
- Tachycardia can be related to blood loss (late sign!) or prolonged labor-look at BP also
- Over 100/min seek reasons (pain, fear, infection…)
What are some cartidac changes during the postpartum period?
- Dramatic change in cardiac output after birth
- Typically stabilizes first PP hour
- Declines 30% in first 2 weeks
- Prepregnancy levels about week 6
What are some hematologic changes during the postpartum period?
- Pregnancy associated activated coagulation continues for variable time
- Increased risk for thromboembolism for up to 6 weeks (deep vein diameter increased)
- WBC counts up to 30,000 – resolves in about a week
- Increase of >30% in 6 hours can indicate infection
- Increased ESR-pregnancy fibrinogen levels several weeks
What are some hemoglobin and hematocrit changes during the postpartum period?
- Changing values r/t fluid shifts and blood loss
- GB/RBC should be close to pre-labor values in 2-6 weeks
- Hemo-concentration occurs with extracellular fluid loss
- 10% drop in hematocrit is a sign of hemorrhage (35-45)
- (>500cc blood loss vaginal/ 1000cc with Cesarean)
- Postpartum anemia (HgB <10) for 6-8 weeks
Describe postpartum weightloss
- 10-12 lbs common with birth
- PP diuresis = 3 kg more in first week (due to decrease in oxytocin lvls)
- Loss of all weight may take 6-8 weeks if pregnancy weight gain in normal range
- Weight loss more rapid with breast feeding, good nutrition, exercise
What are some neurologic changes during postpartum?
- Headaches r/t ECF shift or “leaky” epidural, HTN and stress
- Migraines resume in chronic sufferers
- Epileptics have high risk of seizure in first 24 hrs PP
- Changes in seizure meds (increase the dose)
Describe Postpartum Chills and Diaphoresis
Intense shaking seen after birth
- Thought to be neurologic or vasomotor but exact cause unknown
- No clinical significance but is uncomfortable
- Self-limiting
Diaphoresis
- Another route to eliminate excess fluid
- Night sweats
- No clinical significance but protect from getting cold
Describe postpartum afterpains
- Process of uterine involution, leads to cramps
- More severe in multiparous women or with uterine distension (multiples, large babies)
- Intermittent uterine contractions
- PP Pitocin (synthetic oxytocin) administration and breast feeding worsen pain
- Bladder distension interferes with involution and can worsen pain (and bleeding)
- NSAIDS and pain meds to relieve pain
What would you do for RH negative mothers?
- Baby’s blood type must be identified
- RhoGAM is also given at 28 weeks gestation and after any event that may risk exposure to fetal blood (amniocentesis, miscarriage)
- If baby Rh + and mom is not isoimmunized (antibody screen neg) then RhoGAM must be given PP (usually within 72 hours)
- RhoGAM attaches to fetal hemoglobin (Rhesus D + erythrocytes) and destroys prior to maternal immune system reaction
- RhoGAM screen (Kleihauer-Betke test measures amount of fetal HgB in mothers bloodstream) will be drawn to ensure adequate dose given.
What are the effects of rubella during pregnancy?
- Maternal illness in 1st trimester can cause fetal blindness, hearing loss, heart defects, mental retardation and movement disorders
- If not rubella immune (titer less than <1:8) or equivocal (1:8) must have rubella vaccine (MMR) postpartum – typically done just prior to discharge home
- Advise against getting pregnant for 3 months after receiving vaccine
- Avoid exposure to immunosuppressed individuals (live, attenuated virus).
Describe ovulation during postpartum
- Menstruation resumes 6-8 weeks postpartum in non-breastfeeding women
- 1st cycle usually (NOT ALWAYS) anovulatory
- By 12 weeks, 90% of women menstruate
- Most providers recommend contraception at 3 weeks postpartum for bottle feeding moms
What are the 2 phases of psychological adaptation during the postpartum period?
- Taking in phase
- Talking hold phase
Describe the taking in phase during the postpartum period
Characterized by passivity and dependence on others
- A time to “mother the mother”
- May have a great need to talk about her birth
- Preoccupied with her needs. Food and sleep are major priorities
- Birth to about 2 days PP
- Recruit help
Describe the taking hold phase during the postpartum period?
- Resuming control of body and mothering
- Focuses on baby
- May experience insecurities of ability to care for child
- Family-centered care
Describe some maternal attachment behaviors
- Talks with baby
- Face eye to eye contact
- Touches and holds baby
- Accepts sex and characteristics of baby
- Social and accepts partner support
- Cares for baby (feeds, diapers)
Describe the acquaintance phase
- Initial touching goes form tentative with fingertips to holding enfolded in arms
- Listen to comments about how she perceives the baby
- Responding to baby’s cues increases confidence
- Nurse helps to clarify the baby’s behavior to the mother
- Negative feelings are normal and nurse should reassure
Describe the reciprocity phase
- Mutual enjoyment of each other’s company
- Mutual cueing behavior, expectancy, rhythmicity, synchrony seen
- Forms new relationship and evokes response different than fantasy during pregnancy
- Each looks forward to the other’s company
Describe the Father Interactions postpartum
- Many things father can do to interact with baby besides feeding (BF infant)
- Family-centered maternity care
- Engrossment: Father’s absorption, preoccupation and interest in infant.
- Cultural differences in how involved in care father may be
Describe postpartum blues
- Normal period of lability that occurs from birth up to 2 weeks postpartum – it is an adjustment reaction with depressed mood.
- 50-80% of mothers; worse in primiparas
- “emotional roller coaster”
- Transient, resolves on its own - usually
- Typically starts after discharge home but not necessarily
Causes:
- Psychological changes
- Hormonal shifts
- Fatigue
Describe postpartum depression
- Develops in 10-20% of mothers (actual number might be even greater)
- Onset is later than PP blues - Greatest risk at 4 weeks PP and around time of weaning
- Feeling of Sadness, crying, insomnia, anger and thoughts of harming self (thoughts of harming baby rare = psychosis), worthlessness, impaired concentration
- Diagnosis = at least 4 symptoms, most of the days for 2 weeks
- Responds well to TX: SSRIs and CBT, may need hospitalization