Normal Puerperium & Lactation Flashcards
a normal puerperium lasts how long?
postpartum period lasting 6-12 wks
changes of pregnancy are reversed
immediate puerperium occurs when?
first 24 hrs after parturition
early puerperium occurs when?
24 hrs to 1 wk postpartum
breast milk comes in
remote puerperium occurs when?
period of time required for genital organ involution & return of menses; usually 1st wk to 6th wks
what happens during the immediate puerperium period?
dictated by events of delivery, type of anesthesia or analgesia, complications during delivery
BP & pulse every 15 minutes (preeclampsia can occur up to 6 wks postpartum)
maternal temp at least every 4 hrs (big one is endometritis)
post anesthesia care provided by anesthesiologist or obstetrician
why do we take mom’s temp so often after delivery?
watching for endometritis
what are some of the physical changes that occur during immediate puerperium
placental delivery & involution begins
uterine involution- UCs regular, strong, coordinated, begin to decrease about 12 hrs postpartum
postpartum chills may last up to 60 min
bladder issues during immediate puerperium
urinary stasis
proteinuria
incomplete bladder emptying for 1-2 days
after pains
cramping that occurs during breast feeding- means uterus is contracting down on self
what occurs during early puerperium
cervix gradually closes vagina, perineum, pelvic musculature decrease to nml size, increase in tone episiotomy/tears heal lochia rubra lochia serosa lochia alba
lochia rubra
postpartum vaginal d/c heavies in the first 3-4 days
lochia serosa
more serous, mucopurulent vaginal d/c from 3-4 days to 2-3 wks postpartum
lochia alba
thicker, mucoid, yellowish-white vaginal d/c from 2-3 wks to 5-6 wks postpartum
what occurs during remote puerperium
uterine involution complete by 6-8 wks
lochia ceases about 5-6 wks postpartum
striae fade from red to silver but are permanent
hair pattern returns to nml over 6-15 months pp(postpartum)
when does ovulation begin after birth
can begin as early as 27 days after delivery
avg. 70-75 days in nonlactating woman
avg 6 mo in lactating woman
when doe menstruation begin after birth
at 7-12 wks in nonlacting mothers & as late as 36 mo in breastfeeding mothers
postpartum care
encourage early father/partner involvement
skin-to-skin contact w/ baby should occur in <1hr; rooming-in should be encouraged & supported; support & reassurance to new parents is important; imp. for mother to sleep & regain strength, recover from labor; regular diet ad lib; stool softener PRN; early ambulation encouraged to prevent thrombophlebitits; shower ad lib; IV rehydration PRN
care of the vulva
teach pt to cleanse vulva from anterior to anus, look for signs of infxn; apply ice bag to perineum 1st 24 hrs post delivery; warm sitz baths beginning 24 hrs after delivery; oral analgesics often required; pelvic muscle exercises may be helpful
care of bladder
encourage pt to void as ASAP after delivery; cath placement may be necessary if voiding is too difficult: trauma to bladder during L&D, regional anesthesia, vulvar/perneal pain/swelling or episiotomy
care of breasts
if going to bf, it is ideal to begin on-demand bf <1 hr post delivery; well fitting brassiere very important;
what do you do if pt is not going to bf
ice packs & analgeisics for engorgement if not bf- lactation suppression meds discouraged
avoid nipple stim
milk prod. should stop w/in a wk
postpartum fever
temp >/= 38C (100.4F) on 2 occasions 6 hrs apart
nursery should be notified of maternal fever, esp. in 1st 24 hrs post delivery
look for s/sx of infxns
what are some s/sx of infxn w/ a postpartum fever
enometritis mastitis UTI thrombophlebitis infected tear/ surgical site complications of anesthesia *labs: CBC, UA, others as indicated
suggestion for icing perineum
frozen giant maxipad with witch hazel frozen into it
common postpartum (pp) complications
uterine hemorrhage preeclampsia/eclampsia infxns urinary retention thromboembolism/thrombophlebitis pelvic musculoskeletal pain neuropathy (pudendal nerve damage) sweat a lot/ pee a lot (way to get rid of extra fluid)
pp IMZ
300 mcg of anti-Rh(D) IG (RhoGAM) w/in 72 hrs of delivery if mother is Rh(D)-neg & baby is Rh(D)-pos;
MMR postpartum if not already
Tdap if due
Hep B may be given
when can combination OCs be used in NON-bf women?
2-3 wks pp
what type of OC is safe in bf women?
progestin-only- depo-provera, levonorgestrel
tubal ligation
2nd MC method of contraception used in US
may be performed at time of c/s, 24-48 hrs after vaginal delivery, or immediately pp in women w/ epidural in place
when can IUD insertion be done pp?
at first pp visit (4-6 wks pp)
copper IUD or prgestin-containing IUD
hospital stay times
48 hrs for vaginal delivery
96 hrs for c/s
doesn’t include day of delivery
short stay criteria for early d/c
mother afebrile, VSS amt & color of lochia appropriate firm uterine fundus adeq. urine output no evid of infxn in wound/repair sites mother able to ambulate w/ ease no abnormal physical/emotional findings mother able to eat & drink pp f/u care arranged mother ready to care for self & baby pp hgb or hct nml ABO & Rh type are known IMZ have been administered PRN mother instructions for home care & f/u support persons are avail. in home
minimal caloric req. for adequate milk prod. on avg is?
1800 kcal/day
pp nutrition general info
fluid intake important
balanced, nutritious diet ensures healthy mother & baby
vit. supplements routinely not needed; may recommend to continue PNV
Ca2+, vit B 12, vit D most imp
iron given only PRN
pp considerations
no sex sooner than 2wks pp
contraception methods reviewed
at d/c mother should be given contact info if she has any questions/problems
pp d/c discussion should include
condition of newborn
immed. needs of newborn
feeding techniques, skin/umbilical cord care
recognition of neonatal illnesses
supprot systems available
instructions in case of emergency/complications
importance of CH IMZ
pp f/u care
support & reassurance are extremely important in pp period
involvement of the newborn’s father & extended family
community & hospital support should be easily available for mother & newborn
pp visits for mom time fram
visit & exam 4-6 wks after uncomplicated vaginal delivery
visit & exam 7-14 days after c/s or complicated delivery
most women may resume regular work & activities by 4-6 wks pp
pp visits for mom should include?
interval hx: PE, wt, BP, thryroid, extremities, breasts, abdomen, pelvic adaptation to newborn bf issues discussed OCP reviewed pp depression eval labs PRN (Hgb, pap, TSH) counseling/education PRN- HPV vaccine?
what type of changes during pregnancy & puerperium do mammary glands undergo?
proliferation of alveolar epithelial cells
formation of new mammary ducts
develop. of lobular architecture
epithelium differentiates for secretory activity
increase in breast size (gain 400g each)
hypertrophy of blood vessels, myoepithelial cells, connective tissue
3 stages of lactation
mammogenesis
lactogenesis
galactopoisesis
*multiple, complicated hormonal interactions involved in lactation
mammogenesis
mammary growth & development
requires estrogen & progesterone
lactogenesis
initiation of milk secretion
requires prolactin
galactopoiesis
maintenance of milk secretion
requires prolactin, oxytocin (suckling)
when is lactation initiated?
when plasma estrogens, progesterones, and human placental lactogen levels fall after delivery
how do you maintain established milk secretion?
requires suckling & emptying of mammary ducts & alveoli
how long does it take for prolactin levels to return to nonpregnant levels in absence of suckling?
2-3 wks pp
colostrum general info
premilk secretion present in 1st 2-3 wks pp: yellowish alkaline secretion, may begin in last months of pregnancy
make up of colostrum
higher specific gravity, protein, vit A, Ig, Na, Cl content than mature breast milk
lower carb, K, fat content than mature breast milk
normal laxative action
what drives milk production?
prolactin
others: insulin, cortisol, etc
substrates for milk are derived from?
maternal gut & liver
what is the principal carb in breast milk?
lactose
mature human milk contains what?
7% CHO as lactose 3-5% fat 0.9% protein minerals vit enzymes H2O 60-75 kcal/dL provided to infant
immune support & bf
maternal transfer of Ig thru breast milk provides immunologic defense for the newborn as the immune system develops:
highest output during first wk
all classes of Ig in breast milk (90% IgA)
breast milk is highly anti-infective (primarily leukocytes)
other factors that help protect the infant from dz & develop a nml immune system
what is the avg milk production in bf mother?
120 mL by the second pp day & increases to 300 mL/d by pp days 10-14
what are some things that may increase milk yield?
crying baby
positive family or provider support of bf
anticipation of nursing
sexual stimuli (CNS modulated release of oxytocin)
bf recommendations
exclusive up to 6 months
partial bf 6-12 mo or longer
WHO suggests up to 2yrs or beyond
ongoing practitioner support increases proportion of mothers who bf
giving formula to new mothers at d/c from the hospital has been shown to discourage bf
maternal advantages of bf
convenient, economical emotionally satisfying/ bond w/ infant aids in uterine involution improves GI motility & abosrption delays ovulation may protect against ovarian CA increased wt loss pp
maternal disadvantages of bf
inconvenient for some
yield may decrease if pumping a lot
nipple tenderness, mastitis possible
what are CI to bf?
illicit drug use excess alcohol intake human T-cell leukemia virus type 1 HIV active breast CA active TB or varicella infxn galactosemia of newborn maternal intake of certain meds
advantages of bf in infants
easily digestivle, ideal composition & temp
free of contamination; good source of Ig; improved cognitive development & intelligence
infants have a decreased incidence of what with bf?
diarrhea lower RTIs necrotizing enterocolitis invasive bacterial infxns SIDS obesity CH allergies Type 1 DM Crohn's dz UC lymphoma
disadvantages of bf to infants
slightly increased risk of neonatal jaundice in 1st few wks
not usually possible for infants that are weak, ill, or very premature (cleft palate, choanal atresia, PKU- may be fed expressed breast milk); mothers w/ CF have high Na content in milk
when is it ideal to begin bf?
within 1-2 hrs of delivery
when does milk usually come in?
3rd or 4th pp day
initial discomfort d/t engorgement
baby & getting milk
baby must latch on correctly to suckle effectively w/ the mouth entirely covering the areola; the tongue will milk to nipple to express the colostrum
bf & supplementation
best to avoid supplementing breast milk in the first 6-8 wks unless absolutely necessary-baby is losing wt, severe nipple or breast leasion, pregnant mother, severley ill mother
avoid using artificial nipples, which may_______infant’s suckling reflex
weaken
may use a dropper or tube
preparing to bf
wash the hands w/ soap & water
clean the nipples & breasts w/ water
comfortable positions for nursing
upright or rocking chair
mother lying on her side
using pillow to prop the baby
allow infant to feed on demand how often?
q 3-4 hrs
always bf on both breasts
start bf w/_____min each breast/feeding, working up to________min/side/feeding
5 minutes
5-10 min
what should you do to stimulate suckling reflex or keep baby awake?
stimulate infant’s cheek or mouth
express some milk into mouth
how do you remove infant from breast?
gently open mouth by lifting outer border of the upper lip to break suction
you want to make sure you place the entire_____&_____ in infant’s mouth
nipple & areola
bf should be initiated when after delivery?
< 1 hr post delivery
frequency & duration of feeds should be on demand, but may be?
every hour, 8-12x’s/day in 1st few wks
typically 10-15 min each breast at each feed- depends on milk supply, efficiency of milk transfer, infant’s behavior
feedings initiated based on infant cues
sleeping infant making suckling motions of the lips
moving the mouth toward an object
sucking on the hands
irritation & crying
*should wake newborns up to feed every few hrs
signs of infant satiety
release of the nipple
relaxation of facial muscles, hands
falling asleep while feeding
postpartum care concerning bf
evaluate mother & baby for adequacy of latchin on, suckling, milk production, and assessment of intake
maternal knowledge & resources should be discussed
ideally a lactation nurse will follow up w/ family 48 hrs after d/c
infant assessment of bf
urine output: 6 wet diapers/day
stools: >4 soft stools/day
wt gain/loss: expect 5-7% loss initially; regain birth wt @ 2 wks
jaundice
mother assessment of bf
supplementation
painful nipples
engorgement
mastitis
painful nipples
common! often occur 1st few wks of bf dry heat/application of expressed milk to nipples bet. feeds may help vaseline/lanolin/vit A&D ointment tx candida infxn if present nipple shields only as last resort
engorgement
occurs 1st wk pp
d/t vascular congestion & accumulation of milk
how do you help and prevent engorgement
breast massage & around-the-clock feedings
how else can you help relieve engorgement
oral analgesics
cool compresses
partial expression of milk before feedings will help relieve discomfort & engorgement
mastitis occurs most frequently in?
primiparous mother
what causes mastitis?
coagulase-positive S. aureus
what should be suspected in recurrent or bilateral mastitis?
neonatal strep infxn
what will you see in mastitis?
painful, erythematous lobule in an outer quadrant of 1 breast during 2nd or 3rd wk pp; Ab (antibody) coated bacteria in milk
in mastitis it is important to continue bf why?
prevents milk stasis
what Abx are used to tx mastitis
cephalosporins
dicloxacillin
methicillin
*local heat, well fitted bras also help
what might develop if mastitis is left untreated?
breast abscess- pitting edema & fluctuance over the inflamed area; I&D abscess, start Abx; discontinue bf
indications for suppression of lactation
women who do not desire bf
women who cannot bf
failure of attempted bf
fetal or neonatal death
methods of suppression of lactation
stop or do not begin bf, milk expression, or pumping
avoid nipple stimulation
wear supportive bra
medical suppression w/ bromocriptine or estrogens is not recommended
complications of suppression of lactation
breast engorgement breast pain leaking breasts sx's will generally improve in 2-3 wks oral analgesics helpful
