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
What is the treatment for postpartum blues?
- Common and time-limited
Treatment:
- Rest
- Regular meals
- Reassurance that this passes
- Understanding partner/family
- Help at home
If symptoms persist beyond 2 weeks, or worsen, needs to see provider
What are the symptoms of postpartum psychosis?
- Evident in first 3 months PP
- Agitated, hyperactive, insomnia, irrational, poor judgment, extreme mood instability
- Delusions/hallucinations support her beliefs that she, her baby and/or the world is evil
- 95% of patients respond to treatment
What are the risk factors for postpartum psychosis?
- Previous puerperal psychosis
- History of bipolar disorder
- Prenatal issues like lack of social support, lack of a partner, low SE status
- Obsessive personality
- Family history of a mood disorder
- Previous postpartum depression (#1 risk)
- Primiparous
- Ambivalence about pregnancy
- Hx of mental illness
- Lack of social support
- Lack of stable relationship with partner or parents
- Family h/o of psychiatric disorders
- Majority of moms who develop PP depression have no identified risk factors – so you never know. Screen all PP mothers
What are some characteristics of postpartum psychosis?
- A TRUE EMERGENCY because of the risk of suicide and/or infanticide
- Associated with hallucinations and delusions – delusions about GOD and DEVIL.
- May become convinced the only way to “save” the baby is by killing the baby.
- Immediate inpatient treatment is necessary in most cases to protect self and infant. Will need antipsychotics and psychotherapy.
- Appropriate treatment – majority recovers, but high risk of recurrence in subsequent pregnancies/deliveries.
Describe the postpartum assessment of the perineum
REEDA
- Redness,
- Edema,
- Ecchymosis,
- Drainage,
- Approximation
Describe the intial postpartum assessment immediately after birth
- BP, Pulse
- Fundus consistency, placement and height per protocol; q15 X4 ( first one hour)
- 30 for the second hour
- 4-8H for the next 22 hours or per Hospital protocol.
What are the 3 types of postpartum pain?
Cramping
- NSAIDS such as ibuprofen
Topical perineal pain
- Dermoplast (benzocaine topical)
- Tucks
- Ice packs
Moderate or incisional pain
- Narcotic/acetominophen combo like Vicoden
- Alternate ibuprofen with narcotic combo or give together
How is pain managed post C/S?
- Common to administer long acting Duramorph (about 24 hours) via epidural
- Less systemic side effects
- Regular assessment of RR for first 18-24 hrs
- Usually receive IV Toradol in combination with Duramorph.
- A PCA pump to administer analgesics is not uncommon
- Common meds for PCA pump
- Dilaudid
- Morphine
Describe some important concepts with pain management after C/S
- Keep NSAIDS on a schedule
- Scheduled dosing results in overall less medication use and better pain control
- Remember that mothers are often afraid to take any medications when breastfeeding
- Ask specifically about this if pain is obvious and she refuses meds
- Very little medication enters breastmilk (remember pharm principles of 1st-pass)
What does the acrynom BUBBLE-HE mean?
- Breasts
- Uterus
- Bowels
- Bladder
- Lochia
- Episiotomy
- Homan’s
- Emotional state
What are some teaching associated with bottle-feeding mothers?
- Encourage good supportive bra for a week, even at night
- Avoid nipple stimulation
- Avoid direct warm water in shower
Describe breastfeeding education
- Teach process of lactation-colostrum to mature milk
- Assess nipples
- Provide education on proper mechanics of latch if any redness or cracking seen
- Lactation consult
- Offer to assist with latch
- No soap to nipples
- Medical-grade lanolin for early irritation
What would you assess for in breast-feeding mothers?
Soreness: Deeper latch
Different latch positions
Nurse on least sore side first
S&S of mastitis: sore/localized inflammation, fatigue, flu-like symptoms, fever
Emphasize complete emptying of breasts to minimize risk of mastitis, plugged ducts, if it is not emptied it can increase chances of getting mastitis
How would you assess the uterus postpartum?
- Palpate with one hand supporting the uterus above the pubis, use the other one at the level of umbilicus to palpate fundus
- Measured in fingerbreadths above or below the umbilicus (+1 U or -2 U)
- Asses for any Firmness, height, midline (why do we care?)
- With massage, any free flow? Clots larger than nickel?
Describe the postpartum assessment of the bowels
- Assess for abdominal distension, firmness?
- assess for Bowel sounds
- Flatus/BM
- Constipation – take more fiber
- Nausea/vomiting – give antiemetics
What would you teach a mother postpartum regarding her bowels?
- Normal sluggishness after delivery
- May not have a BM until after discharge
- Reinforce flatus as a positive sign
- Walking and light exercise help to promote bowel motility
- Adequate water, fiber intake and stool softeners
Describe the postpartum assessment of the bladder?
- For any Distention- explain basic physiology behind it
- check for Displacement of uterus
- When did she last void?
- Any pain or burning with voiding?
- Any Urethral tears?
- Perineal water bottle (peribottle) to relieve
- Normal for bladder to be desensitized for first 24 hours
- Diuresis first 2-3 days
- If unable to void, may need to straight cath
How would you assess for lochia in a postpartum women
- Assess pad and perineum
- Assess for clots (ask mother)
- Less than quarter-sized are WNL
- If pad newly changed assess how often changed, pad saturated? Time period?
What would you teach a patient regarding lochia?
- Normal progression of lochia
- Musty, sweaty smell normal
- Foul smell is abnormal
- Pooling of blood during night
- Increased activity can cause a “spurt” of bleeding that is relieved with voiding and rest
What would you assess for with an episiotomy postpartum?
- May assess side lying for better visual
- Remove pad or displace the underwear to inspect the perineum, labia and any repairs (pen light helpful)
- Evaluate REEDA: redness, edema, ecchymosis, drainage, approximation
What would you teach a postpartum women regarding an episiotomy/perineum
- Use of perineal bottle after each void to keep area clean
- Suture material may leave “lumpiness” that mother will always feel
- Topical medications and ice packs to relieve pain
- Oral medications for pain
What would you teach a postpartum woman regarding DVT?
- Avoid long car or plane trips in first 2 weeks PP
- If unavoidable, will need to get up q 2 h and ambulate
What are some nursing diagnoses for postpartum women?
- Pain
- Fluid and electrolyte imbalance R/T hemorrhage or postpartum blood loss AEB..
- Risk for Infection R/T any invasive procedure, wounds, repairs AEB…
- Interrupted Breastfeeding R/T….. (NICU)
- Constipation R/T Surgery, Narcotics, Fear of Pain, Postpartum Status AEB Patient Statements
What would you teach postpartum women regarding their emotional status?
- Get Family centered care
- Do not disapprove of negative feelings; they are a normal stage
- Follow mother’s cues and support her as she gets to know the baby
- Respect mothers who are slower to attach
- Tell mothers relationships develop over time
What would you teach postpartum women regarding sexual adjustment?
- Lochia alba (no pink color) means placenta is healed and sex is OK – usually around 6 wks
- Vagina and perineum can remain tender for weeks
- Dryness can occur with shifting hormones
- Lubricants can help
- Condoms + spermicide as effective as OCP
- Need for contraception if pregnancy is not desired
- Often, a break from the baby will help mothers responsiveness
What are some danager signs postpartum?
- Saturating a peri pad in one hour or less
- Foul-smelling lochia
- DVT signs
- Nausea, vomiting, “flu-like” symptoms
- Area of hardness/tenderness in breast
- Pain with urination
- Any pain that does not respond to pain medication as expected
- Discuss signs of PP depression VS blues
What is postpartum hemorrhage?
2 types:
- Early (first 24 hours after delivery) highest risk
- Late (between 24 hours to 6 weeks after delivery)
Definition:
- Blood loss greater than 500 cc with vaginal birth, > 1000 cc with C/S
- Also defined as a drop of >10 % in hematocrit
What causes early postpartum hemorrhage?
- Uterine atony
- Lacerations
- Episiotomy
- Retained placental fragments
- Hematomas
- Uterine inversion
- Uterine rupture
- Placental implantation problems
- Coagulation disorders
Remember, lochia only accounts for 25% of total blood loss! Most lost in delivery or immediately after.
What can cause uterine atony?
- Uterine overdistension
- Prolonged labor
- Oxytocin augmentation/induction
- Magnesium sulfate, terbutaline use (it relaxes uterine smooth muscle)
- Prolonged third stage (>30 minutes)
- Preeclampsia
- Retained placenta
- Operative birth
- Asian, Native American, Hispanic heritage
What are postpartum lacerations?
What are some risk factors for lacerations?
- Nulliparous
- Epidural
- Precipitous birth
- Pitocin
- Macrosomia
- Forceps/vacuum extraction
- Episiotomy-assess
Describe late or delayed hemorrhage subinvolution, what would you assess for, and how would you treat it?
- Failure of uterus to return to normal size
- Failure of decidua and endometrium to develop over placental site or retained fragments
- Rare (0.7%)
Assessment
- Fundal height not where expected
- Failure of lochia progression (red to alba)
Treatment
- Remove placental frags
- Methergine 0.2mgIM or PO Q3-4 hrs X24 to 48 hrs
- Acts on uterine smooth muscle to increase tone
What are the different types of implantation pathology?
- placenta accreta (adhered to myometrium)
- placenta increta (invasion of the myometrium)
- placenta percreta (penetrates myometrium)
What are postpartum hematomas? Describe them
- It is a Collection of blood; may be caused by injury to a vessel or inadequate hemostasis w/ laceration
- May be visible in groin, labia, or introitus
- May be hidden in connective tissue in vagina or perineum
- Complaints of pain in the area
- Small hematomas (<3cm) respond to ice and pressure after 24 hrs heat (these usually resolve on their own)
- Large may need incision and drainage (vessel ligated)
How would you treat postpartum hemorrhage?
- 1st line treatment for hemorrhage is oxytocin
- 2nd line is uterotonics
- Don’t give methergin if the women has hypertension
- Don’t give hemabate to patient’s with asthma, it causes contractions and acute asthmatic exacerbations, give methergin instead
What is uterine inversion?
- Uterine prolapses through the cervix, you will have to push it back if possible
- Risk factors- uterine relaxants (mag sulfate), abnormal placenta implantation, protracted labor, pulling on placenta
- Managed by physician – uterus repositioned if possible
What would you assess for with a uterine rupture and what are some risk factors?
Assessment:
ÊSevere abd pain. Abd is hard to palpation (bleeding may be hidden)
Risk Factors
ÊPrevious abdominopelvic surgery
ÊPitocin use
ÊMalpresentation of fetus, prolonged labor
ÊGrandmultiparity
Treatment – Emergency surgery
What is mastitis, what causes it, and what are some symptoms associated with it?
ÊInflammation of the mammary gland.
ÊMilk stasis and cracked nipples contribute
Ê↑incidence in first few weeks after delivery
Commonly caused by:
Staphylococcus aureus (S. aureus), Group B streptococci (GBS)
ÊMother feels ill, flu-like with fever
ÊOnly one breast involved
ÊAlways include Inflammatory Breast Cancer when considering mastitis diagnosis
How would you treat mastitis?
Penicillin
What are some risks for genital tract infections
ÊHemorrhage, especially > 1000cc loss
ÊTrauma: laceration or wound
ÊC-section & C/S with prolonged labor
ÊRetention of placental fragments
ÊUntreated vaginal/cervical infection or STI
What organisms cause genital tract infections and how would you treat it?
ÊCommonly caused by Streptococcus species (areobic and anareobic ) A,B (GBS),D
ÊMost common early onset (24-36 hrs) is GBS and late onset is usually Chlamydia
Treatment
ÊPenicillins (natural) or with beta-lactam inhibitors (like amoxicillin clavulanate)
ÊSupportive therapy
What is endometritis and what are some risks for it?
Infection of the endometrium or decidua with extension into myometrium and parametrial tissue
ÊSubinvolution
ÊAscending bacteria
ÊCatheterization
ÊVariable onset R/T organism (GBS earlier) but 2-3 days PP common
ÊWBC may be elevated beyond physiologic leukocytosis of puerperium
ÊComplicates 1-3% of SVD and 5-15% of scheduled C/S
Ê30-35% after prolonged labor and C/S
What are the signs and symptoms for endometritis?
ÊPyrexia (usually PP day 2-3)
ÊTachycardia
ÊChills (w/ severe infection)
ÊUterine tenderness extending laterally
ÊMalodorous, seropurulent lochia
What is parametritis?
Pelvic cellulitis or infection of parametrial structures
ÊAscension of infection from injury (laceration) to connective tissue and ligaments and into the pelvis
ÊMay be caused by pelvic thrombus and resultant tissue necrosis
How would you care for a patient with a postpartum infection?
- Antibiotics as ordered
- Monitor I/O
- Wound care to local trauma as ordered
- VS, temp and labs
- Monitor labs CBC, coags, H&H
- Support breastfeeding/pumping
What are the signs and symptoms of DVT?
- Edema lower legs
- Mild fever
- Tenderness, erythema, pain at site
How would you diagnose and treat a DVT?
Diagnosis
- Ultrasound
- Venogram and/or lung scan if suspected PE
treatment:
- Heparin and oral Coumadin
- Titrate for INR between 2.0 and 3.0 and PT times (norm 11-16 secs)
- Bed rest, elevation
- Thrombectomy
- Vena cava filter severe cases
What is perinatal death?
includes embryonic death, spontaneous abortion, missed abortion, fetal death and neonatal death
What are Miscarriage/Spontaneous Abortions?
- pregnancy loss less than 500 grams and before 20 weeks gestation with no signs of life. 15-45% of pregnancies end in miscarriage.
- State of Texas considers 20 weeks and 350 grams “viability”.
What is a live born infant?
regardless of gestational age, showing any evidence of life such as beating of the heart, pulsation of the umbilical cord or defined movement of voluntary muscles, whether or not the umbilical cord has been cut or the placenta is attached.
What is a termination/abortion?
- Medical Interruption/Termination because of health risks for the mother, for genetic reasons or due to a diagnosis of fetal anomalies.
- Abortion of a presumed healthy fetus through conscious choice
What is a stillbrith?
Fetal death after 20 weeks. Even with extensive evaluations, the cause for a baby’s stillbirth cannot be recognized in 60% of cases.
What is neonatal death?
Death of a newborn within the first 28 days of life.
