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Normal Postpartum/PP complications Flashcards

1
Q

What occurs in the first 4 hours after birth?

A

Maternal organs start to undergo readjustments to the nonpregnant state

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2
Q

What is the nurses role in the 4th stage of labor?

A

Identify and manage and deviations from normal
Promote and support parent-infant bonding
Prevent hemorrhage

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3
Q

How often should assessments be in the 4th stage of labor? What should assessments include?

A

Q 15 min x 4; Q 30 min x 2, Q 1 hr (dependent on institution)

Vital signs
Fundus, lochia, perineum, bladder

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4
Q

What is included in the focused postpartum exam?

A

General assessment, vital signs and pain assessment
BUBBBLEE
Breasts
Uterus
Bladder
Bowels
Bleeding
Legs
Episiotomy/laceration/c-section incision
Emotions

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5
Q

How does the HR change in postpartum?

A

may see mild bradycardia r/t baroreceptor stimulation immediately PP, then returns to prepregnant states by 24-48 hours

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6
Q

What is the BP changes in postpartum?

A

increase days 4-6 then normalizes by 2-6 weeks

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7
Q

When do respirations go back to normal?

A

Increased RR when pregnant

Within 24 hours

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8
Q

When does temp go back to normal PP? Why mild elevation in 1st 24 hours? Why rise on 3-4 day?

A

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

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9
Q

How much does blood volume decrease by in PP? By what mechanisms?

A

Blood volume decreases 1000-1500 ml

Diuresis
Night sweats
Blood loss
More humidity in breath with exhalation

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10
Q

How does CO change PP? When does it return to normal?

A

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.

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11
Q

When auscultating the heart what might you hear?

A

Still might hear a systolic murmur d/t increase blood in pregnancy

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12
Q

What is the PP change in respirations? When does it return to normal?

A

Immediate decrease in pressure on the diaphragm and reduction in pulmonary blood volume

Rate back to normal within 2-3 days

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13
Q

What complication are you assessing for when auscultating the lungs? What does this mean for BC?

A

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

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14
Q

What head to toe approach should be used in PP?

A

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

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15
Q

What labs might be drawn PP? What might be seen?

A

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)

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16
Q

What assessments and education are recommended for an individual breastfeeding/chestfeeding?

A

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

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17
Q

What assessments and education for an individual bottle-feeding/formula feeding?

A
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18
Q

What does the latch score evaluate for? What does a higher score mean? What should the score be by 12 hours of age?

A

evaluates feeding effectiveness

The higher the score the more effective the feeding

By 12 hours of age the score should be >6

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19
Q

What does LATCH stand for?

A

Latch
Audible swallowing
Type of nipple
Comfort (breast/nipple)
Hold (positioning)

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20
Q

What is involution?

A

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

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21
Q

What are the causes of after birth pains? Comfort measures?

A

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

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22
Q

What occurs to the fondus in PP?

A

Must remain firm to control bleeding from the placental site
Support lower uterine segment

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23
Q

What is included in the assessment of the fondus after birth?

A

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

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24
Q

What are the causes of a “boggy” uterus?

A

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

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25
When do the kidneys return to normal?
By 1 month
26
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
27
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
28
What occurs in bowels initially? When does it normalize?
Decreased intestinal tone and motility Normal by 2nd week
29
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.
30
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)
31
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
32
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
33
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.
34
What is lochia? What are the stages? Will they revisit any stages?
Consists of sloughed off necrotic endometrial tissue and blood 1. Rubra = darker, brighter red first 3-4 days 2. Serosa = pinkish/brown, less amount 3/4 days- 10 days 3. 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.
35
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)
36
What is a scant amount of Lochia?
Blood only on tissue when wipe or less than 1 inch on peri pad within 1 hour
37
What is a small amount of Lochia?
Less than 4 inch stain on peri-pad within 1 hour
38
What is a moderate amount of Lochia?
Less than 6 inch stain on peri-pad within 1 hour
39
What is a heavy amount of Lochia?
Saturated peri-pad within 1 hour
40
How much is too much Lochia? Too big?
> 1 pad saturated per hour Clots > Egg/golf ball
41
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
42
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
43
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
44
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
45
DTRs and clonus? What is this a s/s of?
Checking for hyperreflexia S/S of pre-eclampsia
46
What hormone decreases PP? What does this cause?
Estrogen levels decrease Decreased lubrication/libido
47
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
48
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
49
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
50
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.
51
What should be assess for a C-section incision?
Dressing is clean and dry for first 24 hours and removed with first shower Redness Ecchymosis Edema Discharge Approximation
52
What are signs of positive attachment?
Holding (en-face) Calling by name Talks, coos, sings to baby Asks questions about baby Cares for baby Face to face
53
How do we help moms have positive attachment to infant?
Early contact - skin to skin Rooming in Assist/encourage parents to preform care Allow partner/family to stay Education Support with feeding Identify risk factors Foster bonding by keeping baby with mom
54
What are the blues? Onset? Resolve?
Most common form of postpartum mood change - may be dramatic First few days Resolves by 2-3 weeks
55
What are the cause of the blues?
Fatigue Uncertainty Frustration Hormonal fluctuations Unrealistic expectations Lack of sleep and support
56
What is the treatment for the blues?
Rest, support, reassurance
57
What is the Edinburgh Postnatal Depression Scale (EPDS)?
Developed in 1987 to be used by primary care providers to identify pregnant/PP patients at risk for post natal depression Early identification of depression is crucial to the well-being of patient and baby
58
What is the EPDS administered?
Prenatally: at initial visit, 28 weeks Postpartum: prior to d/c from hospital, at 2 and 6-week postpartum visits, prn
59
What occurs in the EPDS? How many points?
Asked to select the response that best matches how they have felt in the last 7 days Total points possible is 30 which represents the most severe symptoms
60
What is considers a positive EDS screening? What are the first trimester threshold for EPDS? Second/third? PP?
Answers yes to question #10—”The thought of harming myself has occurred to me…” First trimester > 11 Second/third trimesters > 10 Postpartum- >/= 13 considered positive screen
61
What other factors may influence the the EDS screening?
Understanding of the language Fear of consequences if depression is identified (stigma, etc) Different emotional reserves
62
What vaccinations/medications should be given PP?
Rubella non-immune: give MMR Varicella vaccine if not immune Rh negative mom with Rh positive fetus: Rhogam 300 mcg within 72 hours Tdap if not given in pregnancy COVID
63
When should planning/discharge teaching begin?
Planning and education for discharge should begin at first interaction after birth and continue throughout the hospitalization
64
What should all patients be educated on PP?
Rest Nutrition Hygiene Baby Care PP expectations Pelvic rest Warning signs for postpartum complications
65
What are PP complications?
PE Cardiac disease HTN Hemorrhage DVT Infection Postpartum depression
66
What are the leading causes of maternal mobility and mortality?
Infection Hemorrhage HTN Emboli (high risk hypercoagulative state)
67
What is early/primary hemorrhage?
First 24 hours after birth
68
What is late/secondary hemorrhage?
Over 24 hours - 6 weeks PP
69
What is considered normal blood loss during vaginal or cesarean?
less than 1000ml
70
What blood loss is considered a hemorrhage?
more than 1000ml blood loss
71
What do the 4 T of PPH?
Tone Tissue Trauma Thromboembolic disorders
72
What causes decreased tone? What issues does tone cause r/t PPH?
Too full, too fast, too long, too much Pitocin, or meds that stop CTX's, Magnesium sulfate, grand multip, prior infection.  Basically lost its tone so does work well. Too much stretch that it doesn’t work as well, infection b/c when sick body doesn’t want to work as well.
73
What tissue put patients at increase risk for PPH?
Retained placental pieces so uterus can't clamp down/contract as well
74
What trauma put patients at increase risk for PPH?
Episiotomy, lacerations, sulcus, cervical, uterine rupture, hematomas, uterine inversion
75
General treatment for PPH includes?
Prevention is best Fundal massage Bimanual compression 2nd IV for fluids Empty bladder Medications Initiate breastfeeding when mother & baby stable Pain meds – help control pain, heal better.
76
What does breast feeding do for PPH?
body produces natural oxytocin to help the uterus contract
77
How much Pitocin should be given to contract uterus in PPH?
10 units IM (in leg) or 10-40 units in 500 ml NS “wide open”
78
How much cytotec should be given to contract uterus in PPH? Route? MOA? SE?
Cytotec 800-1000 mcg SL or rectally Prostaglandin and increased uterine tone Shiver fever and diarrhea
79
How much Metherigne should be given to contract uterus in PPH?
Methergine 0.2mg IM (NO HTN) q2-4hr Consider 0.2mg PO q6h x4 (maintenance dose once PPH controlled or for a patient with retained products with manual sweep.)
80
How much Hemabate should be given to contract uterus in PPH? Contraindication? SE?
Hemabate 250mcg IM q15min x3 up to 2 grams Contraindication: asthma SE: explosive diarrhea give immodium to prevent
81
How much TXA should be given to contract uterus in PPH? MOA? When is it given? Can it be given again?
TXA 1 gram IV or 1 gram PO Reduce bleeding by inhibiting breakdown of blood clots in fibrin within 3hr from delivery If given the initial dose of TXA within 3 hours of birth, can still have a second dose within 24 hours
82
What are two ways to describe the fondus after birth?
Firm - GOOD Boggy - BAD soft and possible clots passing
83
What is the treatment for PPH retained tissue?
2nd IV Prep patient/family communication Assist with US(look for parts) Manual removal PAIN MEDS Surgery (NPO) -D&C Antibiotics prophylactically for infection prevention
84
What is the difference between accrete, percreta, and increta?
Accrete - placenta is growing inot endometrial lining – least severe  Percreta - placenta imbedded inside muscle Increta - through the uterus into the organs
85
What is the difference between a manual sweep and manual removal?
Manual sweep – taking out remaining product Manual removal – take out whole placenta
86
When is a trauma PPH more common?
with operative vaginal delivery like forceps or vacuum
87
For trauma PPD r/t lacerations what is the treatment?
Have suture Anesthetic Sterile gloves Good light Sponges Can also assist with visualization of tissue
88
What occurs in hematoma? Treatment?
Up to 500 ml can accumulate in the “potential space” of the iliorectal fossa Packing Watchful waiting or evacuation Ligate “bleeder” NPO if OR
89
What are the s/s of a hematoma r/t PPH?
Can occur before any vulvar bruising or discoloration noted by RN Feel pressure - need to push S & S of hypovolemia out of proportion to estimated blood loss (EBL) - dizzy Pain is disproportional to reported perineal laceration and repair
90
What are the causes of a uterine inversion?
Grand multiparity –elasticity/ ligaments aren’t tight so hard to hold uterus inside Mismanagement of the 3rd stage –pulling too much on cord --> pulling it out Unlucky
91
What is the treatment for a uterine inversion?
Put it back in the vagina by grabbing onto it, pushing it all the way up and then making a fist This is an emergency
92
When are thromboembolic disorders typically diagnosed? If not then, when? Treatment?
Prior to labor Before labor notice there is no clotting on the floor, looks watery Identified prior then orders for clotting factors or platelets
93
When is a code white called? Is there maternal death?
once you have done all the things and none of that works Sometimes it’s still not enough- Maternal death
94
What treatment is used in a code white?
Support team: Interventional radiology, additional OB, blood bank, lab, anesthesia all come to the unit Uterine balloon tamponade Arterial embolization Uterine suturing techniques Ligation of arteries Hysterectomy
95
What does a bakri balloon do?
puts pressure against uterus on help it contract down and can be kept in for 12-24 hours
96
What does uterine suture technique do?
forcing uterus to contract down
97
Uterine artery litigation, uterine suture, and bakri balloon all ....
Maintain fertility
98
What is late PPH? What are the possible causes?
After 1st 24 hours up to 6 weeks postpartum Can wake up in bed full of blood. Atony, retain fragments (tissue), infection, unknown
99
What is the treatment for late PPH?
IV access US of uterus to see if empty D&C Medications (Methergine, Pitocin, Hema bate, Cytotec, TXA) Antibiotics b/c something inside uterus Ligation of uterine arteries Hysterectomy
100
What are the risks for endometritis? (8)
C-section PROM Multiple SVE’s (cervical exams) FSE/IUPC Vacuum/forceps Diabetes Intraamniotic infections during labor** Pre-existing infections
101
Where does endometritis begin? Where does it spread? If it is not treated what occurs?
Begins as  localized infection at placental site  Can spread to include the whole endometrium If not treated can lead to Pelvic cellulitis (parametritis), septic pelvic thrombophlebitis, frank septicemia & death
102
What are the s/s of endometritis?
Maternal fever Chills Increased pulse Uterine tenderness Foul smelling lochia
103
What is the treatment for endometritis?
Antibiotics D&C if had retained tissue and subsequent Oxytoxics (any medication to help with the bleeding)
104
What is the cause of a UTI PP? Diagnosis? Treatment?
Causes: Catherization during labor or after deliver, inability to urinate postpartum (numbing from epidural). Tx: UA (nitrates) and urine culture, C&S Rx: Appropriate antibiotic, antibiotic safe for breastfeeding.
105
What is the danger with UTI? Treatment?
Can lead to Gram negative septicemia - pyelonephritis May require IV antibiotics May need to disrupt breastfeeding “pump and dump”
106
What are the causes breakdown of episiotomy/laceration? S/S?
Poor tissue (genetics, poor nutrition, diabetes), poor technique, infection, unknown “I feel like I’m gaping open!”
107
What is the treatment for breakdown of episiotomy/laceration?
Antibiotics Repair if within 3 days   After 3 days, debridement and healing by secondary intent.
108
What is the worst case r/t breakdown of episiotomy/laceration?
Necrotizing fasciitis (Group A Streptococcus “flesh eating”)
109
What are the causes of a an infection of C/S incision? What should nurses look out for?
Poor tissues (diabetes, obesity) Poor technique Unknown Paralytic ileus. She is a surgical patient and we need to monitor for BM and gas (chew gum)
110
What is the treatment for a infection of C/S incision? (7)
Debridement Irrigation Packing Healing by secondary intent Antibiotics. Peri pad over incision so extra moisture isn’t developing After shower letting it air out
111
What ate the s/s of mastitis?
High fever Breast tenderness Redness over clogged duct Infected lobule Red streaks “Cancer of the whole body”
112
What is mastitis treatment? What is the treatment if patient gets an abscess?
Antibiotics for staph aureus, dicloxicilin drug of choice. Requires I&D (incision and drain), D/C breastfeeding until healed, antibiotics
113
What is mastitis? Can you continue to breastfeed with mastitis?
Stasis of milk in the milk duct and trauma occurs to the nipple from breast feeding or a pump and bacteria is introduced to newborn You can and should continue breastfeeding
114
What are the blues? When does it occur? S/S? Treatment?
Most common form of postpartum mood change first few days, resolved by 2-3 weeks Can be dramatic, start crying or feel angry Rest, support, reassurance. Sleep when baby sleeps. Let them know that they are common
115
What are the causes of the blues?
Fatigue,  Uncertainty Frustration Hormonal fluctuation Unrealistic expectations  Lack of sleep and support
116
When is the onset of PP depression? Causes?
Any time in the first year Hormones, chemical imbalance, genetic predisposition lack of sleep, role transition
117
What are the risk factors for PP depression?
Hx. of any depression or postpartum depression Primips (first time moms) Lack of social support (DV, poverty) Complicated labor/delivery  Adolescents
118
What is the treatment for PP depression? (6)
Ask Support groups Anti-depressant (most safe to use breastfeeding) Help at home Sleep Reassurance that she is not alone
119
When does PP anxiety occur? Causes?
Any time in the first year Hormones, chemical imbalance, genetic predisposition lack of sleep, role transition
120
What are the risk factors for PP anxiety?
History of any anxiety or other mental illness Family history of anxiety Previous pregnancy or infant loss Complicated labor/delivery History of thyroid disorders
121
What is the treatment for PP anxiety?
CBT/other therapies Anti-anxiety meds - safe during breastfeeding Help at home Sleep Support
122
What are the s/s of PP anxiety?
fear, worry, intrusive thought (constantly thinking about safety or baby), feeling on edge, stress, overwhelmed, restless, panic attacks, restless sleep
123
What are the risk factors for PP psychosis? What is the treatment?
Hx bipolar OCD stress Hospitalization with baby, but never left alone Antipsychotic medications Therapy
124
What are the clinical feature of PP psychosis?
Sleep disturbances Depersonalization Psychomotor disturbances Euphoria with hallucinations/delusions (may include SI/HI) Want/do kill themselves or their babies
125
What is the difference between onset of PP psychosis and PP depression/anxiety?
PP depression and anxiety generally starts after the PP blues whereas this begins as early as 3 days PP

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