module 7 Flashcards
involution
shrinking of uterus from pregnant state back down to pre-pregnant state
subinvolution
- uterine atony (no tone of uterus)
- if involution doesn’t happen
uterine contractions
- continue after delivery of baby and placenta
- caused by oxytocin
- uterus shrinks back down to a grapefruit size
- helps close off blood vessels when placenta separates
- oxytocin may be given postpartum to promote contraction of uterus
- breast stimulation promotes oxytocin production
afterpains = painful contractions after birth
- commonly experienced by women who have given birth previously or had a multifetal pregnancy, a large baby, or uterine distention r/t polyhydramnios
- most pronounced during breastfeeding
fundus immediately after delivery
2 cm or finger breadths below the umbilicus
fundus first 4 hours after delivery
rises at or above the umbilicus (1cm)
fundus 24 hours PP
at umbilicus, steadily shrinks down
- steady descent if 1 cm or finger breadth per day
what is lochia
lochia ruba appearance, composition, duration, abnormalities
appearance = dark red
composition = blood, decidua, and other pregnancy debris
duration = 3-4 d
abnormalities = foul odor (suggest infection), saturation of pad in 15 min or less, tissue, clots larger than plums, duration more than 4 days
lochia serosa appearance, composition, duration, abnormalities
appearance = lighter red, pink, or brown
composition = debris, old blood, white blood cells, serum
duration = 10-14 d
abnormalities = saturation of pad in 15 min or less, foul odor (suggest infection), bright red blood for more than 1-2 h
lochia alba appearance, composition, duration, abnormalities
appearance = yellow or white
composition = WBC, serum, mucus, and bacteria
duration = 2-4 wk
abnormalities = foul odor (suggest infection), bright red blood for more than 1-2 h
how to assess the uterus
- nurse should stabilize the lower uterine segment with one hand and palpate the fundus with the other
- if we just start pressing on fundus without supporting, it can cause prolapse
primary hemorrhage
- postpartum hemorrhage in firsts 24 hrs
secondary hemorrhage
- postpartum hemorrhage 24 hrs-12 wks
REEDA (perineum assessment)
r - redness
e- edema
e - ecchymosis
d - discharge
a - approximation
assessing the perineum
- assess for signs of infection, varicosities (hemorrhoids from diminished peristalsis, slowed GI system, wt of belly, pooling of blood that happens with dilated vessels), trauma, and healing
- have women lay on her side with leg lifted and knees bent
for perineal pain:
- Tylenol and ibuprofen commonly ordered
- dibucaine ointment to put in pad for numbing
- ice packs may be applied (especially for the first 24 hours after delivery)
- after 24 hours, use more moist heat to promote circulation (sitz bath)
- use peri bottle each time to go to the bathroom
- colace to ensure stool is soft so less likely to cause pain or require pushing
sitz bath
- basin of warm water that goes under the toilet seat, IV bag filled with warm water is hung, open clamp and water gently comes down into toilet bowl
- promotes circulation, prevents infection by gently cleaning the area, comforting
colostrum
- produced the first few days after birth and continues until milk comes in
- thick, yellow, sticky
- sometimes produced during last trimester
- usually just several drops (very small in amount)
- rich in antibodies that the baby needs
interventions to aid with breast discomfort after delivery
- firm supportive bra
- ice packs can be applied after feeding to minimize swelling/inflammation
- assess infant’s breastfeeding latch to minimize discomfort and ensure a successful feeding
- assess for cracks, blisters, bruising, inflammation
- lanolin soothing ointment, vitamin E, gel packs that can go in bra after feeding
typical blood loss for vaginal delivery
200-500 mL
typical blood loss for cesarean delivery
up to 1000 mL
do pulses increase or decrease immediately after birth
decrease
sign of postpartum hemorrhage (cardiovascular)
thready, rapid pulse
decreased BP with increased pulse
hypovolemic shock sign (cardiovascular)
weak pulse
increased risk for DVT, PE
- increased clotting factors during pregnancy put mom at risk
- not mobile if in labor for a long time
monitoring of HCT, HGB
- change in 10 points from pre-delivery indicated PP hemorrhage
- hemodilution in pregnancy applicable to immediate PP period - expect a little bit lower hematocrit
estrogen levels after delivery
return to pre-pregnancy level within 2 weeks in women who are not breastfeeding
- if breastfeeding, it will take longer
prolactin levels after delivery
prolactin increases in response to the decrease in estrogen
- helps breastmilk production
BUBBLE - EE (B - first)
Breast
- should be symmetrically soft and non-tender for the first 24 h postpartum, becoming slowly and progressively more full until milk comes in sometime between postpartum days 2-5
BUBBLE - EE (U)
uterus
- should be firm and midline, descending from the umbilicus toward the pelvis at a predictable rate
BUBBLE - EE (B - second)
bladder
- encourage frequent emptying of the bladder, because a full bladder can displace the uterus and cause atony
- infrequent emptying of the bladder may also predispose a woman to cystitis
BUBBLE - EE (B - third)
bowel
- bowel motility may be slow to recover from the birth and the hormones of pregnancy
- women who delivered by cesarean section are more likely to experience an ileus (lack of movement of intestines)
- women may not have a bowel movement before discharge
- passing flatus and positive bowel sounds are sufficient proof of bowel function
- first bowel movement should be within 24-48 hours after delivery
BUBBLE - EE (L)
lochia
- assess and record the amount of lochia per protocols of the institution
BUBBLE - EE (E - first)
episiotomy/perineum
- assess any episiotomy wound or other laceration, as well as the general condition of the perineum
- assess for hemorrhoids
BUBBLE - EE (E - second)
extremities
- assess the patient’s legs for unilateral edema, warmth, induration, or tenderness, any of which may suggest a thromboembolism
BUBBLE - EE (E- third)
emotional status
- extreme mood swings, anxiety, and depression are cause for concern
taking-in phase
- occurs immediately after delivery
- the mother is focused on her own recovery and takes a passive, dependent role
- not a great time to do teaching with mom because she is self-focused
taking hold phase
- the mother processes the birth experience and transitions to independent behavior
- start to take on mother role
- teaching and reassurance
letting go phase
- the mother acknowledges her new normal and sees the baby as a person instead of an idea
- nurses promote bonding
- confidence
- new normal
C-section considerations
- recovery can take up to 6 weeks
- remain hospitalized for 3-5 days
- foley left in until they can ambulate
- assess for flatus
- dressing over c-section incision generally removed after 24 hrs
- staples removed before discharge
- do not lift anything heavier than the infant for 4-6 wks
- should not drive if taking opioid
c-section complications
- ileus (caused by diminished peristalsis)
- endometritis (inflammation of the lining of the uterus)
- blood clots
- wound complications (dehiscence, infection, or hematoma)
- surgical injury
- hemorrhage
discharge teaching after birth: nutritional needs
- if mom is breastfeeding, should increase calories 500 calories a day above what they were consuming in pregnancy
- increasing hydration with a caffeinated beverage
- increased protein for wound healing
discharge teaching after birth: contraception
- if not breastfeeding can get pregnant within 6 weeks or sooner
- discuss goals
- if breastfeeding = progesterone only pill
discharge teaching after birth: sexual activity
- abstain from sex for at least 6 weeks after delivery
- if have stitches, wait for the okay from provider
- when lochia is completely gone, the cervix is closed and they can have sex
discharge teaching after birth: smoking
go outside to smoke and put alternate covering on so that the baby is not exposed to secondhand smoke
patients should be taught to immediately report the following
- new onset leg pain and warmth (DVT)
- chest pain, SOB, feelings of impending doom (PE)
- return of heavy, bright red lochia lasting more than a few hours (possible secondary PP hemorrhage)
- sustained depressed mood or sadness (possible PP depression)
- thoughts of hurting oneself or infant (possible PP psychosis)
signs of infection
- elevated temp and foul smelling lochia
uti signs
burning, pain, or frequency of urination
uterine infection signs
pelvic pain, abdominal tenderness
mastitis sign
localized firm areas of redness on breast, especially with flu-like symptoms
hemostatsis after delivery affected by
- increased circulating blood volume
- uterine contractions
- hyper-coagulability
primary causes of hemorrhage
- uterine atony
- retained placental fragments
- genital lacerations/trauma
typical blood loss after vaginal birth and c-section
vaginal = 500 mL
c-section = 1000 mL
PP hemorrhage is bleeding more than….
1000 mL despite uterine massage and first line uterotonics (oxytocin)
first intervention if you walk in a room and see mom has heavy lochia
assess/touch fundus
next steps to heavy lochia
If boggy → atony → massage the fundus to increase tone of uterus
○ If massage does not make uterus firm → oxytocin IM or bolus
○ Methergine, misoprostol
○ If you see hemorrhaging and know that the fundus is firm → know the cause is something
else (coagulation issue, laceration, hematoma that we cant see from outside) → call provider
reasons for atony
- retained placental and/or membranes
- failure to progress in the second stage of labor
- adherent placenta
- LGA infant
- labor induction
- prolonged first or second stage of labor
- high parity (5 or more pregnancies with gestation periods greater or equal to 20 wk)
- uterine overdistension
- uterine infection
treatment for PP hemorrhage
Call for help.
○ Fundal massage of a boggy uterus.
○ Assess for lacerations or hematoma if the fundus is firm.
○ Bladder catheterization for inability to void.
○ Establishing intravenous access.
■ Large bore
■ Fluid boluses
○ Oxytocin administered as a first-line uterotonic medication.
○ Misoprostol
○ Methergine
○ Lower HOB and feet raised → trendelenburg position
■ Blood will circulate to major organs ○ O2 supplementation
symptoms of PE
dyspnea, cough, sweating, and
pleuritic chest pain.
○ Medical emergency
○ Educate new moms on s/s because it often happens after they go home
symptoms of DVT
swelling, pain, localized redness, warmth, and tenderness.
● DVTs are often diagnosed with ultrasound imaging.
superficial vein thrombosis symptoms
pain, tenderness, and redness along the length of the vein. The vein may feel cord-like. A superficial vein thrombosis is often self-limiting.
care for lacerations
Dibucaine ointment
● Ice/sitz bath
● Constipation protocol
○ Ambulation
○ Hydration
○ High fiber diet
○ Stool softners around the clock
first degree laceration
superficial
second degree laceration
goes into the perineal muscle and anal sphincter; requires stitching
third degree laceration
increased tearing of anal sphincter and perineal muscle; requires stitching; painful
fourth degree laceration
tearing right into rectum, very painful, lots of stitching and healing time, can be repaired in OR under anesthesia
fourth degree laceration
tearing right into rectum, very painful, lots of stitching and healing time, can be repaired in OR under anesthesia
If hematoma less than 3cm
comfort care
If hematoma greater than 3cm
excise, drain, cauterize
hematoma nursing care
Pain meds
○ Ice
○ Careful assessment
○ Urinary catheter because hematoma can press on urethra
General symptoms of a postpartum infection include:
A fever that persists beyond the initial 24 hours after birth.
○ A fever that begins 2 to 10 days after birth.
○ Elevated WBC count that continues to rise rather than fall.
risk factors for PP infections
operative vaginal delivery
○ Prolonged second stage of labor, pushing for a long time
○ Third- or fourth-degree laceration
○ Meconium-stained fluid
Endometritis:
infection of the lining of the uterus.
Endometritis risk factors
chorioamnionitis, prolonged labor, and prolonged rupture of membranes.
Endometritis s/s
Fever
○ Uterine tenderness (tenderness that wasn’t there before, pain felt when mom is hugged)) ○ Flu-like symptoms
○ Tachycardia
○ Foul smelling lochia
- treated w/ IV broad-spectrum antibiotics
Lactational Mastitis:
inflammation of the breast tissue often associated with infection
- milk stasis
Factors contributing to mastitis
delayed breast emptying, poor drainage of one or more
ducts, inconsistent pressure on breasts (like poorly fitting bra), oversupply of milk, or nipple trauma.
mastitis s/s
tender, red area of breast, malaise, or a high fever.
○ Feel very sick
mastitis treatment
Cold compresses
○ NSAIDs
○ Regular and complete emptying of the breast
■ Mom has to remove the milk
○ Antibiotics: broad spectrum
○ Increase hydration
postpartum blues
transient, self-limiting mood disorder that starts 2 or 3 days after delivery and resolves within 2 weeks.
○ Rapid shift in mood; up + down: happy then crying
Postpartum depression
major depression with an onset during pregnancy or in the first 4 weeks
after birth.
○ Goes on longer than 2 weeks postpartum
Postpartum psychosis
rare disorder that affects a woman’s sense of reality.
diagnosed with postpartum depression
a woman must meet at least five of the nine diagnostic criteria for major depressive disorder during a 2-week period with at least one of the symptoms being a depressed mood or diminished pleasure in all or most activities.
Warning signs for postpartum depression include:
Low mood for at least 2 weeks
○ Negative attitude toward the infant
○ Anxiety about the health of the infant
○ Concern about the ability to care for the infant
○ Use of alcohol, street drugs, drugs prescribed to others, or tobacco
Disturbance of a woman’s perception of reality as evidenced by:
hallucinations
○ thought disorganization
○ disorganized behavior
○ Delusions
