Normal Postpartum/PP complications Flashcards
What occurs in the first 4 hours after birth?
Maternal organs start to undergo readjustments to the nonpregnant state
What is the nurses role in the 4th stage of labor?
Identify and manage and deviations from normal
Promote and support parent-infant bonding
Prevent hemorrhage
How often should assessments be in the 4th stage of labor? What should assessments include?
Q 15 min x 4; Q 30 min x 2, Q 1 hr (dependent on institution)
Vital signs
Fundus, lochia, perineum, bladder
What is included in the focused postpartum exam?
General assessment, vital signs and pain assessment
BUBBBLEE
Breasts
Uterus
Bladder
Bowels
Bleeding
Legs
Episiotomy/laceration/c-section incision
Emotions
How does the HR change in postpartum?
may see mild bradycardia r/t baroreceptor stimulation immediately PP, then returns to prepregnant states by 24-48 hours
What is the BP changes in postpartum?
increase days 4-6 then normalizes by 2-6 weeks
When do respirations go back to normal?
Increased RR when pregnant
Within 24 hours
When does temp go back to normal PP? Why mild elevation in 1st 24 hours? Why rise on 3-4 day?
return to normal within hours PP
Could be transient mild elevation (< 100.4 F) in 1st 24 hours d/t general inflammation rx after labor, epidural
Could be transient temperature rise on 3-4th day – d/t breast enlargement –> mature milk –> inflammation
How much does blood volume decrease by in PP? By what mechanisms?
Blood volume decreases 1000-1500 ml
Diuresis
Night sweats
Blood loss
More humidity in breath with exhalation
How does CO change PP? When does it return to normal?
increases 60-80% immediately PP due to relief of the inferior vena cava obstruction and contraction of the uterus followed by rapid decline to prelabor values within 1 hour
Pre pregnancy states by ~ 2 weeks.
When auscultating the heart what might you hear?
Still might hear a systolic murmur d/t increase blood in pregnancy
What is the PP change in respirations? When does it return to normal?
Immediate decrease in pressure on the diaphragm and reduction in pulmonary blood volume
Rate back to normal within 2-3 days
What complication are you assessing for when auscultating the lungs? What does this mean for BC?
Pulmonary emboli from estrogen
Pulmonary edema
Wait for BC with estrogen for 6-8 weeks if not breast feeding. If breast feeding wait until not breast feeding b/c affect milk supply
What head to toe approach should be used in PP?
Depression, anxiety, fatigue
Fevers, chills
Dizziness, syncope with ambulation
Nausea, vomiting
Headache, visual changes, RUQ/epigastric pain (pre-eclampsia)
Chest pain, palpitations
Difficulty breathing, SOB (sign of PE)
Dysuria
Pain with bowel movement
Difficulty with moving/ambulation
What labs might be drawn PP? What might be seen?
CBC
Common to see WBC elevation 12,000-20,000 + in labor and postpartum (might mask infection)
HELLP labs (hemolysis, low platelets, increased liver enzymes)
What assessments and education are recommended for an individual breastfeeding/chestfeeding?
No soap on nipples
Assess how well latching is going - nipple trauma sign baby isn’t latching well
Alternating breasts
Put finger in corner of the mouth to break suction and decrease trauma when pulling baby off
Lanamlin on nipple to decreasing chapping
Supportive bra to provide support and comfort and avoid underwires because increases chance of milk duct being clogged
Look at nipples to see if they are everted, flat, or inverted
Look for red hard lump sign of matasitis
Breast feed every 2-3 hours during day and every 2-3 hours at night until mature milk comes in then can space out
What assessments and education for an individual bottle-feeding/formula feeding?
What does the latch score evaluate for? What does a higher score mean? What should the score be by 12 hours of age?
evaluates feeding effectiveness
The higher the score the more effective the feeding
By 12 hours of age the score should be >6
What does LATCH stand for?
Latch
Audible swallowing
Type of nipple
Comfort (breast/nipple)
Hold (positioning)
What is involution?
Immediate postpartum: halfway between SP and U
1 hour PP: at U
Next 6 weeks:
Cells atrophy and shrink
Returns to non-pregnant location in pelvisby ~ 6 weeks
Rate of descent: 1 cm per day until a pelvic organ at about 10 days
What are the causes of after birth pains? Comfort measures?
Oxytocin - more intense contractions the more babies you have had because the uterus has been stretched multiple times, so the uterus has to work even harder to contract and prevent hemorrhage
BF causes oxytocin to be produced –> more pain
NSAIDS, alternate tylenol and Motrin, heating pad, lay on belly with pillow under uterus to help it stay contracted
What occurs to the fondus in PP?
Must remain firm to control bleeding from the placental site
Support lower uterine segment
What is included in the assessment of the fondus after birth?
Firm (hand above symphysis and umbilicus - feels firm grapefruit) or boggy (wet sponge that compresses easily)
Position in relation to umbilicus
Deviated R or L of umbilicus
What are the causes of a “boggy” uterus?
Pieces of placental tissue
Cclot sitting in there
Having lots of babies
An infection in uterus in labor
Full bladder can elevate uterus and cause it to not contract
When do the kidneys return to normal?
By 1 month
What happens to the kidneys PP?
Ureters and renal pelvices-hypotonia/dilation takes 2-8 weeks to normalize
Transient increase in BUN and proteinuria-caused by breakdown of uterine tissue and slowing of GFR
Since there is a decreased sensation to void for 24 hours r/t birth and epidural what occurs? What should a patient void PP?
Urinary retention
Full bladder displaces uterus –> Increased Bleeding
Void within 6 hours after birth
What occurs in bowels initially? When does it normalize?
Decreased intestinal tone and motility
Normal by 2nd week
When is the first BM PP?
First 3-5 days postpartum because they may have had a BM in labor and they may not have eaten much or at all in labor. Talk to pt about what to expect with this.
What does hemorrhoid care look like?
- Prep H (hemorrhoid cream)
- Witch Hazel pads - line peripad with witch hazel and keep in fridge (helps to reduce the inflammation and provides comfort)
What are additional consideration regarding the bowels with 3rd and 4th degree lacerations?
Stool softener, because you don’t want them to strain while going to the bathroom d/t the laceration.
Dermaplast for hemorrhoids and perineal pain
Nutrition/diet PP?
BF individuals need an additional 500 calories for milk production. No foods that you can’t eat when breastfeeding. Each baby is individual and baby will decide what it may or may not like
Alcohol: can drink occasionally, feed first, have beverage, wait for a few hrs to BF again
What patients is it especially important to listen for BS?
Assess in particular with c/s patients because you need return of bowel sounds post anesthesia and abd surgery.
You are watching for potential ilius.
What is lochia? What are the stages? Will they revisit any stages?
Consists of sloughed off necrotic endometrial tissue and blood
- Rubra = darker, brighter red first 3-4 days
- Serosa = pinkish/brown, less amount 3/4 days- 10 days
- Alba = white 6-8 weeks
Sometimes, at day 14 pp, they may go back to Rubra like the sloughing off of a scab causing more oozing of the darker red bleeding. Would only have this for a day or so.
What does assessment of Lochia include?
Color
Amount (scant, mild, moderate, heavy)
Clots
Gushing
Odor
Weight (all pads for first 4 hours PP including all clots)
What is a scant amount of Lochia?
Blood only on tissue when wipe or less than 1 inch on peri pad within 1 hour
What is a small amount of Lochia?
Less than 4 inch stain on peri-pad within 1 hour
What is a moderate amount of Lochia?
Less than 6 inch stain on peri-pad within 1 hour
What is a heavy amount of Lochia?
Saturated peri-pad within 1 hour
How much is too much Lochia? Too big?
> 1 pad saturated per hour
Clots > Egg/golf ball
How do you know its lochia?
From uterus
Slow flow from vaginal opening
More spits or gushes with uterine contraction, fundal massage, or breastfeeding
Pooled lochia will be darker in color and coagulated
How do you know it is non-lochial? What might cause this?
Not form uterus - form unidentified tear
Contracted/firm uterus
Constant flow
Especially heavy, bright red
What occurs in the extremities PP? Relief measure? Resolves when?
Initial increase because 3rd spacing r/t normalizing in BV and fluids in labor
Drink fluids, elevate legs, full length compression stockings, walking
Will resolve in 1 week
What is Homan’s sign? Sign of? What else should you look for?
Pain in calf when dorsiflexion in foot
S/S of DVT
Look for pain, streaks, heat, masses
DTRs and clonus? What is this a s/s of?
Checking for hyperreflexia
S/S of pre-eclampsia
What hormone decreases PP? What does this cause?
Estrogen levels decrease
Decreased lubrication/libido
When do Lacerations/Episiotomy heal? What activity should be done?
Usually heals and suture dissolves by 6 weeks but may take longer for 3rd/4th degrees
Pelvic rest and no intercourse so at least 2 weeks but ideally 6 weeks until followup
What do you look at when evaluating Lacerations/Episiotomy? Position to assess?
Redness
Edema
Ecchymosis
Discharge or Drainage
Approximation
Have patient roll side to side with one leg up to assess to see perineal area better
What should be included in perineal care PP?
Peri bottle to dilute urine and relieve discomfort
Wiping/patting dry from front to back
Ice pack for 24 hours
Tucks pad
Dermoplast spray
Witch hazel pads
Sitz bath 2-3 times daily after 24 hours
What are the type of skin closures for C-sections? What does the fundal assessment look like?
Stables removed before discharge and steri-strips are applied for them to go home
When doing fundal assessment: Place hand over the incision point and press on the top of the fundus.
