Module 2 PP Flashcards
Postpartum care
Puer Perium
Puer= child Perium= to bring forth
Antepartum
Before the onset of labor
Nurses will call these women “AP”
Intrapartum
Time of labor and birth
Refer to these woman as women in labor
Postpartum
6-8 week time period after delivery of baby and placenta to the return of the reproductive system to the non-pregnant state; often known as the 4th stage of labor. It’s a time of great transition as the body is adjust cloth physically and psychologically.
Physiologic Adaptation
Involution- term that refers to pelvis reproductive organs returning to their approximate ore pregnant, size, position & function
There’s a great risk of postpartum hemorrhage until involution is complete
Top of the uterus is referred to as
The fund is
It’s where we palpate the uterus
Involution
Refers to the uterus but also refers to other pelvic organs
Facts about involution
Most rapid change occurs within first 3-4 days
Will occurs most rapidly in women who had an uncomplicated labor and delivery process
Early ambulation and breast feeding will > the rate of involution
Breastfeeding releases the hormone oxytocin which causes contractions of the uterus
Synthetic oxytocin is called Pitocin “Pit”
When would involution be at risk for moving more slowly?
Anything that may by getting in the way of the muscles of the uterus (myometrium), from contracting down.
Over-distention of the uterus may make contraction more difficult.
Overdistention is caused by
Multiple fetuses
Polyhydramnios- excess amount of amniotic fluid
Incisions made into the myometrium (C-section)
Retained placental tissues (this tells the brain the body is still pregnant & will inhibit contraction)
Having a full bladder
These things can cause a postpartum hemmorage
Involution occurs more rapidly with
Breastfeeding
Normal labor & delivery
Early ambulation
Complete expulsion of the placenta
Involution occurs more slowly with
Multiple gestations (fetuses) C-section Polyhydraminos Retained placenta Full bladder Multiple pregnancies Prolonged labor
When the placenta detaches from the endometrium
It leaves a 7cm in diameter area, despising very large blood vessels
The uterus undergoes rapid contractions that vasoconstrict or pinch off these blood vessels at the site of placental attachment to control bleeding.
What is the blood flow rate to the placenta
6-8 mL per minute
For involutionnto occur you need
There delivery of the placenta, the contraction of the uterine wall after birth, and protein catabolism! So the uterine muscles cells decrease in size
The placenta site needs to heal
How long does it take the placenta site to heal?
6 weeks!
It takes other parts of the endometrium 3 weeks
The process of the placental site healing is called?
Exfoliation.
It’s the sloughing off of dead tissues in the form of Lochia
It leaves the site smooth and without scar tissue that allows for the implantation if fertilized ova in subsequent pregnancies
Where can the fundus be palpated after delivery?
Midline and halfway btn the pubic symphysis and the umbilicus
It’s contracted and will continue contracting for ~1-2hours
Afterwards, it’s relaxing and the fungus returns to the level of the umbilicus or slightly above
What hormones are responsible for the contracts and decrease in the size of the uterus
Decreasing levels of the hormones estrogen and progesterone
Increasing levels of oxytocin
How long after delivery of the placenta will large uterine contractions occur?
1-2 hours to prevent postpartum complications. Still want a firm uterus, not a BOGGY uterus
Boggy uterus means that the uterus has not contracted to a smaller size, leaving it open to postpartum hemorrhage
Afterpains
Contractions after delivery that shrink The uterus
Stronger and more painful in multiparous women
Can also be experienced during breastfeeding (Nipple stimulation, oxytocin released)
relief with: pain medications, positioning, ambulation, warm blankets, or relaxation techniques
At what rate does the fundus continue to descend into the pelvis?
1cm or finger breadth a day. We use fingerbreadth
Document how many fingerbreadths and WHERHER OR NOT IT IS MIDLINE
How long after birth should the fundus be unpalpable
10-12 days postpartum
It’ll be back behind the symphysis pubis
Lochia is
Postpartum discharge classified by it’s appearance and contents
What is the progression of Lochia?
Lochia Rubra- first 1-3 days
Lochia Serosa-3-10 days salmon (pale serosanguinous) to light brown
Lochia alba- 10-14 days creamy yellow/white might last as long as 6 weeks
Acceptable Lochia rubra
Should be like heavy menstrual bleeding- if saturating a pad in < 50 min. or pooling intervention is needed.
Clots ok if smaller than grapes. Clots the size of plums require investigation. Clots should only have blood and residual debris
What does Lochia serosa contain?
Old blood, leukocytes, serum, and tissue debris
What does Lochia alba contain?
Mainly of mucus and leukocytes
Women who have experienced disease action (also c-section) will have lochia alba that
Might be lighter but will still have the same progression
If a woman is in the stage of Lochia alba and starts have bleeding again
This is a sign of a complication like retained placenta and potentially a risk for hemorrhage
Important to note the odor of the discharge, could smell is indicative of infection
After delivery the cervix
Protrudes into the vagina
After a week the cervix is dilated to
1cm
It never regains it’s oval opening but is instead a slot with possible scar tissue from lacerations
What happens to the vagina?
The vagina walls are smooth after delivery and rugae do not return until ~4 weeks postpartum.
Vagina never returns to its ore-pregnancy size, but will < in size and return to a near pre-pregnancy state as postpartum period progresses
The vagina will add pear edematous
Why is urinalysis retention a risk factor for postpartum women?
Because of the the labia become so edematous
Episiotomy/ laceration repairs
Cutting so the babies head can come out
Dyspareunia
Vagina dryness/ painful intercourse due to decreased estrogen levels
When does menstrual flow continue for women after birth
Non-lactating women: 6-9 weeks
Ovulation resuming in 70% of these women by 12 weeks
Menstruation not resuming until lactating women have stopped breastfeeding. Mean time to ovulation is 6 months
What is responsible for ovulation suppression?
Prolactin levels are responsible for ovulation suppression
They are influenced by the frequency, duration, and intensity of the feedings of the newborns as well as any supplements
Cardiovascular changes that occur during pregnancy
Blood volume, cardiac output, and coagulation
Large > in blood volume and cardiac output
Hypervolemia allows women to tolerate blood loss during birth
How much blood do women lose from birth
500ml from vaginal delivery
800-1000 with C/S
True or false? A woman’s cardiac output will decrease after birth?
FALSE
A woman’s CO will increase after birth because there will be > blood flow back to the heart when blood from the placenta comes back to her body.
As well as mobilization of the excess extracellular fluid back into her vascular components.
When does Cardiac Output go “back to normal” after delivery
It takes about 12 weeks for cardiac output to decrease to normal
Postpartum women pee and sweat a lot to get rid of excess fluid accumulated during pregnancy
What are the technical terms for pee and sweat?
Diuresis and diaphoresis
What hormone is increased during pregnancy?
Aldosterone! To help them maintain high CO
How much fluid do postpartum women excrete per day?
Up to 3,000ml
The peeing doesn’t end with pregnancy!
However, urinary retention directly after pregnancy which can lead to UTIs
What happens to blood characteristics as postpartum women pee out all their fluid
Since there’s a great loss of plasma volume (that’s greater than RBC) there is a temporary rise in hemoglobin and hematocrit levels
This makes it difficult to do blood tests after birth. Her WBC will > to as much as 30,000, making it useless to determine infection
Thus you must assess volume stats and blood characteristics often for baseline and watch for other signs of infection
Fibrinogen is
A clotting factor that along with other clotting factors is responsible for clotting of the blood
Will stay increased for several days after delivery
Postpartum women are at increased risk for developing blood clots
Need to walk although incontinence is common
What happens when the bladder becomes dissented in postpartum
The bladder can displace the uterus upward and to the right, which prevents the uterine muscles from contracting properly and can lead to postpartum hemmorage
Must minister for bladder distension, firmness of the fundus, and bleeding during postpartum period
What are the signs for a UTI in a postpartum woman?
Tenderness over the costovertebral angle, fever, urinary frequency or urgency and painful urination
When are women at their highest fall risk?
Early after delivery they might be dizzy bc of the analgesics
Are headaches common after birth
Yes, frontal and bilateral headaches in the first week postpartum and may be a result of fluid and electrolyte changes
Are severe headaches common after birth?
No! They could be a sign of post-puncture resulting from regional anesthesia like an epidural
These headaches will be relieved is she assumes a supine position
Symptoms of preeclampsia
Headache with blurred vision, photophobia, protenuria and abdominal pain
2 neurological cues to watch for
Maternal fatigue
Headaches
There will be transient neurological changes and CARPEL TUNNEL IMPROVEMENT WTF?
Postpartum endocrine
Estrogen and progesterone <
Low levels of estrogen promote lactation (prolactin) since estrogen is a prolactin inhibiting hormone
Not breastfeeding will cause estrogen levels to rise (prolactin not inhibiting estrogen anymore)
If breastfeeding menstruation should not return for 12 weeks
Relaxin
A hormone that causes the relaxation of ligaments and joints during pregnancy
Feet may remain relaxed and be bigger
Abdominal wall is weakened and may split in two
Progesterone
Will cause smooth muscles to relax, making bowel tone sluggish
It’s okay to poop even if they just had stitches
AMBULATE AMBULATE AMBULATE
What’s the most important thing for women to do after birth
AMBULATE
Will spider nevi and palmar erythema disappear after pregnancy?
They should bc of decreased levels of estrogen
Melanocytes stimulating hormone
< after delivery so hyperpigmentation will go away
Colada’s will disappears but stretch marks and linea nagra fade but do not go away
When would an immuno reaction occur btn baby and mom?
Mom is Rh - baby is Rh +
Would need 300mcg of RhoGram within 72 hours after delivery
What other vaccine might have to be given to non immune mothers?
Rubella
Live vaccine so avoid pregnancy for one month
What hormones stimulate milk production during pregnancy?
Human placental lactogen
Prolactin
What hormones prohibit lactation?
High levels of progesterone and estrogen
Before milk is secreted from the breast
Colostrum will be secreted in the third trimester of pregnancy
Milk will be secreted about 2-3 days after placenta expelled
It will be bluish-White milk
What does colostrum contain?
High in protein, antibodies, and immune cells
What has more protein colostrum or mature milk?
Colostrum has more protein
The amount of milk secreted is influenced by the frequency and the length of time the babe suckles
Let down reflex
1) suckling initiates
2) hypothalamus stimulates posterior pituitary to release oxytocin and anterior pituitary to release prolactin
Oxytocin stimulates milk release.
Prolactin stimulates additional milk production
Benefits of breastfeeding
Antibodies given
Lower allergy incidence
bonding experience
> intellectual development
Only breast first 6 months. Breast+ other food for 12 months
Maternal benefits of breastfeeding
-Assists with involution process (oxytocin release)
-< risk of postpartum hemmorage -Causes weight loss
< risk of osteoporosis
< risk of bone cancer
> bonding
When should breastfeeding begin after delivery?
ASAP
Skin to skin important to help baby with transition to extrauterine life
GRT BABY TO BREAST WITHIN 1 HOUR OF DELIVERY
The dour common breastfeeding positions
Football hold- under one arm
Lying down-parallel bodies
Cradling- typical
Across the lap- baby lies on back, close to cradling
The nurses assessed an 8 hour postpartum patient.fondings include Lochia rubra, and a firm fundus. What do you do?
Document findings and continue to monitor. She’s doing good!!
Methergine is used
To control excessive bleeding like in a a hemmorage
Reva Rubin maternal adaptation
Rubin’s restorative phases
1) taking in (dependent): women self absorbed, focusing on what she just experienced
2) Taking hold (independent): taking care of baby
3) letting go (interdependent): letting go of past life
Attachments
Positive-happy kissing loving
Mal- refusing to look at infant, touch or hold infant, refusing to name the infant, negative comments about infant
-can occur bc of traumatic birth experience
Want to support mother
Postpartum blues occur in 80% of women. It should stop in about a week
Newborns’ and Mothers’ Health Perception Act (NMHPA)
Provides minimum stay
- 48 hours vaginal
- 96 hours C/S
Infant requirements for discharge
Vital signs documented for 12 hours One urine and BM passing w/o aid TWO successful feedings No documented anomalies No bleeding at circumcision site for 2 hours Hep B administered PCP identified Congenital Cardiac Heart Defect screening Newborn hearing screening
Discharge education
Care of mom Care of baby Breastfeeding/ bottle feeding When to call OB When to call Pedi
Sudden Infant Death Syndrome
Occurs before age 1 A diagnosis of exclusion SIDS not predictable Leading cause of death 1month-1yr Most coming 2-4 months of age AA 2x if risk American Indian/ Alaskan native 3x at risk More SIDS deaths in winter months More make babies die if SIDS Unaccustomed tummy sleeping > risk 18x
SIDS theory
Babies on bellies expelle CO2 and then reinhale it and pass out
HBIG
?
HBIG versus Hepatitis B vaccine
HBIG- Hepatitis B Immune Globulin- immediate, short term protection against Hep B
Need vaccine bc it’s long term
Postpartum Assessments
Vitals Signs Comfort Immunizations Determine educational needs Consider religion and culture Assess for language barriers Intimate partner violence
Postpartum temperature
should be < 100.4 F (38 C), elevated temp in 1st 24 hours may be related to dehydration, presume infection
w/ >100.4 on two occassions 6 hours apart;
Postpartum shiver or chills common
Postpartum Pulse
Tachycardia may be a sign of infection, hypovolemia
pain/anxiety together w/ tachypnea may be early signs of shock/impending hemorrhage. May occur prior to drop in BP
Blood Pressure
– elevated BP postpartum is not normal/ low or falling BP could be related to orthostatic hypotension or hemorrhage
•Orthostatic hypotension = risk for falls (fainting)
What should you assess in postpartum C/S
1) BMs
2) incisions sight
3) Lungs
Postpartum Assessment BM
-bowel obstruction (pain meds= slow BM assess bowel sounds regularly)
-early ambulation, > po intake (avoid carbonated bevs & straws)
may need enemas, stool softeners, antiflatulent meds
Postpartum Assessment use
REEDA
Redness Edema Ecchymosis-discoloration bc bruising Discharge Approximation
Postpartum Assessment Lungs
Pulmonary infections may occur bc of immobility & use of narcotics
TCDB, splint incision, use incentive spirometer every 2 hours
Focused postpartum Assessment
-B – Breasts •U – Uterus •B – Bladder •B – Bowel •L - Lochia •E – Episiotomy
- H – Homans
- E – Emotional
- B – Bonding
Breasts
- Inspect for size, contour, asymmetry & engorgement
- Note any reddened areas, tenderness, engorgement, warmth, febrile
- Check nipples for cracks, redness, fissures
- Nipples flat, inverted or erect?
- Edu. women on use of bra 24 hrs
- Assess for correct latch-on technique if mom is breastfeeding ->video of proper latch
- If women is non-lactating ->Avoid stimulation
Uterus (part 1 direct assessment)
- Assess with women lying flat and have her void
- Always support the bottom of the uterus during any assessment of the fundus. (prevents uterine prolapse)
- Is it firm or boggy
- If firm and bleeding continues think laceration
- midline vs. deviated
- Vagina- any lacerations or hematomas
Uterus (part 2 pain)
- Intermittent uterine contractions due to involution (afterpains)
- Afterpains > in multiparous women than primiparous women
- Interventions for afterpains –
- prone position and place a small pillow under her abdomen
- Ambulation
- Medicate with a mild analgesic
Bladder
- Monitor output/ assess for retention
- Postpartum Diuresis
- Void within 4 hrs after birth
- Early ambulation
- Catheterize if unable to void
- Assess for UTI’s
Bowel
- Anatomy returns to normal location
- Relaxin depresses bowel motility
- Diminished intraabdominal pressure
- Incontinence if sphincter lacerated
- Spontaneous BM 2nd – 3rd post partum
- 6-8 glasses of water or juice
- Stool softener
- Laxative
- Sitz bath for discomfort
- Medications for hemorrhoids
Lochia
- Educate mother on the stages of lochia
- Caution mother that an > in amount, foul odor or return to rubra lochia is not normal
- Instruct patient to change peri pad frequently
- Peri care after each void or during to dilute acidic urine and promote comfort if laceration or episiotomy
- Best practice is to weigh the pads to get accurate blood loss volume
- 1 gram weight= 1 mL
Epistiotomy
They cut midline or mediateral
Peri care includes:
• Peri bottles, Ice packs first 24 hours, hot afterwards (Sitz baths)
• Topical medications- witch hazels pads, dibucaine, dermoplast, epifoam
• Gentle pat dry
Lacerations after episiotomy
Lacerations
•1st degree – perineal skin and vaginal mucous membrane
•2nd degree - includes the fascia and perineal muscles
•3rd degree - extends into the rectal sphincter –NO SUPPOSITORY
•4th degree -Extends through the anterior rectal mucosa exposing the rectal lumen-NO SUPPOSITORY
Hemmorhoids/Homans r/o
Must rule these out
Homan’s sign is for DVT but is not always reliable
Homans’ sign: With the woman’s knee flexed, the nurse dorsiflexes the foot.
Pain in the foot or leg is a positive Homans’ sign.
Emotional Adaptation
Postpartum Blues
•Transient period of depression
•Occurs first few days after delivery
•Mother may experience tearfulness, anorexia, difficulty sleeping, feeling of letdown
Postpartum depression occurs in about 10–20% of all postpartum pts.
Bonding
Take into account cultural factors with this assessment •Describe level of attachment to infant •Is mother attracted to newborn? •Is mother inclined to nurture infant •Does mother act consistently? •Is mothering consistently carried out?
Intimate Partner Violence
A pattern of coercive control that one individual intermittently exerts over another •Power and Control •Emotional / Psychological Abuse •Verbal Abuse •Physical Abuse •Sexual Abuse •Financial Abuse •Spiritual Abuse
Cycle of violence
Tension building phase
Explosion phase
“Honeymoon” or remorse phase
Associated Nursing Diagnosis
- Risk for infection
- Risk for deficient fluid volume
- Acute pain
- Risk for impaired parenting
- Risk for ineffective breastfeeding
- Risk for constipation
- Risk for ineffective health maintenance
- Risk for impaired urinary elimination
- Deficient knowledge
- Disturbed sleep pattern/fatigue
What causes ovulation suppression?
Elevated serum prolactin levels
Serum prolactin levels are influenced by the frequency, intensity, and duration of breastfeeding
Diuresis
Results from a < in the adrenal hormone aldosterone
Postpartum Cardiovascular & hematologists adaptations
1) heart returns to normal position
2) CO elevated transiently
3) diuresis &diaphoresis
4) > WBC
5) > fibrinogen(risk for clots!)
6) Hb and Hematocrit levels
Hb= 12-16. Ht-= 37-47%
Renal postpartum adaptations
1) possible bladder distention
2) risk of urinary retention
3) protienuria resolves by the 6th week postpartum
< aldosterone production
< Na+ retention
> urinary production
Neurological postpartum adaptations
1) Maternal fatigue
2) Transient neurological changes
3) Headaches (Severe headaches result from regional anesthesia)
4) Carpel tunnel improvement
Physiological postpartum Adaptation
Estrogen and progesterone <
Anterior pituitary- prolactin for lactation
Expulsion of the placenta, placental lactogen, cortisol, GH, and insulinase levels decrease
Musculoskeletal System postpartum
Relaxin hormone subside
Ligaments and joint supposedly return to prepregnacy states. Abdominal wall is weakened and muscle one of the abdomen is diminished
Diastasis recti
Separation btn the abdominal wall muscles
Direct application is appropriate for first 24 hours. Afterwards use…what?
First 24 hours= ice packs
Second 24 hours= Sitz bath
Peri care topical meds
Witch hazel pads, dibucaine, dermoplast, epifoam
