Post-partum Flashcards
Fourth Stage = Puerperium
Close observation -> 1st hr Vital signs for 15 minutes for first hour and 30 minutes 2-4 hours after Identify hemorrhage Identify complications Ongoing education Ongoing support
Early Maternal Assessment
Vital signs
Psychosocial
Vital signs
Temperature—below 100.4oF – mom dehydrated
Pulse—bradycardia – shift in fluid volume
NO change in BP or RR
Psychosocial
Bonding = bonds to baby
Lack of Attachment – two way street both mom and baby
Adolescents
Poor coping skills
Mental health disorders
Attachment Process
Taking-in period – dependent
Mom wants care for herself
Bodily concerns – food/sleep/comfort
Talk about labor; lasting up to a day
Taking-hold period – dependent/interdependent
Strives to master infant-care skills
Assume responsibility
Letting-go - interdependent/independent
Postpartum depression may occur
Might return to work or relinquish a portion of child’s care to other caregivers
5-6 weeks out
Maternal Assessment
Breasts
Breastfeeding vs. non-breastfeeding
Breastfeeding moms
Colostrum – yellowish color
Tenderness or engorgement – warm showers help milk come in; prolactin is responsible; 2-4 days to come in
Non-breastfeeding moms
Engorgement – tight bra and ice packs
MASTITIS “Breastmilk Stasis”
Precipitating factors:
Inadequate breast drainage
Plugged duct
Poor let-down
Not rotating infant positions
Cracked nipple, fissures
Sometimes: infection
Staph Aureus, E. coli
Mastitis — History and Physical Exam
HCP?
Diffuse myalgias, “flu-like” symptoms, breast pain
Wedge-shaped, erythematous, tender, flaking skin
Usually unilateral -> Upper, outer quadrant most common
Fever – low grade temperature does not indicate systemic infection, do not stop breastfeeding
Observe carefully for signs of abscess formation
HCP = abscess, eruption and skin breakdown, temperature above 102
Mastitis Treatment
DO NOT stop breastfeeding on the affected side, empty the breast
If mild, symptoms occur for less than 24º and may resolve with frequent nursing or pumping and supportive measures: bed rest, fluids, analgesics
Fever of 102˚ -> may be tx with antibiotics. Antibiotic options include dicloxicillin or cephalexin or clindamycin up to 14 days
Uterus
Immediate post partum vs. 2-4 hours
Fundus
Immediate postpartum:
halfway between the symphysis pubis and the umbilicus
2-4 hours postpartum:
level of the umbilicus or one fingerbreadth above
Uterus Involution – back to pre-pregnancy size
Postpartum Hemorrhage
Defined as: Blood loss >500 ml for vaginal delivery Blood loss > 1000 ml for C/S Classified as: Early, acute or primary Within 24 hrs Late or secondary 24 hrs to 6 wks after delivery
4 T’s
TONE: uterine atony
TISSUE: retained placenta
TRAUMA: lacerations/uterine rupture
CLOTTING: coagulation
Uterine Atony = relaxed uterus
Marked hypotonia of uterus - leading cause (70-90%) of PPH complicating 1/20 births (5% of all births)
Overdistention
full-term multiples
macrosomia
Prolonged labor (having troubles contracting during labor will carry over after)
Induction and augmentation with pitocin
Anesthesia
Prolonged third stage (more than 30 mins)
Preeclampsia (magnesium sulfate)
Vacuum/forceps delivery (manipulation of uterus)
Hemhorrage
Less Frequent
Retained placenta Nondherent retained placenta Adherent retained placenta Inversion of uterus Subinvolution of uterus
Traumatic injury
Lacerations of genital tract
Uterine rupture (hemorrhage)
Excessive force on umbilical cord - delivery of placenta
Coagulation Disorder
Prolonged clotting - rare
Bladder
Void = 4-6 hours postpartum
Anticipate maternal diuresis – Urine volume and flow returns to pre-pregnant by 2-3 days
Retention – frequent voids of less than 150mL; contributes to boggy fundus (high and displaced to the right = full bladder)
Bowel
Strategies to prevent constipation
Relaxin—depresses bowel motility; no food in 24 hours
Perineum = sore, hemorrhoids, she might not want to use the bathroom
Early ambulation
Abundant fluids
High-fiber diet
Lochia
Composition
Endometrial tissue, blood, lymph
Stages
Rubra (red): 1 to 3 days
Serosa (pink, brown-tinged): 3 to 10 days
Alba (yellowish-white): 10 to 14 days, but can last 3 to 6 weeks and remain normal
Episiotomy
REEDA
Or Laceration
REEDA – redness, edema, ecchymosis, discharge, approximation
Vagina: NO SEX for the first 6 weeks
Hematoma (obstructing urethra, larger than a fist=HCP)
Unremitting pain and pressure Careful assessment Implement pain relief measures Hemorrhoids Need to approximate episiotomies and lacerations
Post-Cesarean BUBBLE-HE
Increased risk respiratory problems (anesthesia, sedentary)
Pain
incisional, rather than perineum discomfort
may have long-acting morphine from epidural
Positioning for BF
Abdominal distention– may be normal or indicate infection
Harder to assess uterus
Limited lochia
Compression:
SCDs (sequential compression device)
Venodyne boots
TED stockings
Grief response
Mother/Infant interaction
Surgical Procedure
Major Risks
Major risks
Respiratory Depression
Anesthetic gases or medications (epi/spinal)
Maternal or Newborn respiratory depression
Infection –> Pre-operative prevention
Surgical Care Improvement Project Measure, pt must have antibiotic within 2 hours
Thrombophlebitis - DVT Risk of Pulmonary Embolism Thromboembolism Pulmonary Emboli (4)
Increased blood volume
Venous stasis in lower extremities
Hypercoagulation
Compression of inferior vena cava in 3rd trimester
Thromboembolic Disease Nursing interventions (6)
Nursing Interventions:
Complete bedrest with bathroom privileges
Measure leg circumference
Anticoagulation therapy
Analgesics
Increase fluids
Elevate extremity; TED hose; apply moist, warm packs
Prioritize Nursing Interventions
Post partum
- Fundal massage
- Administer oxygen
- IVF
- Medications
Oxytocin (Pitocin) - common post C-section
Methylergonovine (Methergine) – C/I with HTN
Carboprost (Hemabate)
Misoprostol (Cytotec) – off-label use; rectal, stimulates contractions - Frequent vital signs
- Accurate I/O
- Insert foley
Obtain laboratory tests
Hemorrhage treatments – 2
Internal Tamponade -- reverse foley Internal Tamponade (Bimanual) -- provide compression to decrease bleeding; feel around for placenta/tissue if not responding to fundal massage
Emotions - Attachment
Maternal touch First 24 hrs progresses from discovery phase Touches infant with finger-tips Enfolding the infant Consoling behaviors and face to face Identifies specific features R/T family members Claiming or binding in Maternal sensitive period
Verbal expressions
Progresses from referring to infant as “it” to “he” or “she”
Finally calling the infant by name
Psychosocial Behavior
First 3 months most vulnerable Postpartum blues “Baby blues” Postpartum depression Postpartum psychosis Physiological response—tiredness, fatigue
C/S moms: grief response to unanticipated delivery can complicate attachment***
Postpartum Depression
10 to 15% women
Loss of interest, apathy, lack of emotional response
Feelings unworthiness, shame, guilt
Sleep disturbances, hopelessness, anxiety, insomnia
Panic attacks, suicidal thoughts
May not pick up on infant’s cues or smiles
Negative infant reaction
Symptoms > present at least 2 wks
Postpartum Psychosis
Onset within first 8 weeks after childbirth
Distinguishing signs: hallucinations, agitation, confusion, suicidal/homicidal thoughts, delusions, sleep disturbances, loss of touch with reality
Requires hospitalization
Mental health / Behavioral health (3)
Mental health disorders during the postpartum period have implications for mother, newborn, and entire family
Interfere with attachment to newborn and family integration
May threaten safety and well-being of mother, newborn, and other children
Anti-depressant Drugs
Drugs safe to use while breastfeeding
Sertraline (Zoloft)
Paraxetine (Paxil)
Clomipramine (Anafranil)
Drugs of concern
Fluoxetine (Prozac)
Due to long half-life
Reports of colic, tremors, and insomnia in newborns
Self-Care and Discharge Instructions (5)
Maternal Self-Assessment
Fundus and lochia
Hygiene
Abdominal incision
Pain management
Temperature
Nutrition, Elimination
Fatigue, Mood
Weight loss, Exercise
Sexual Activity, Contraception
Pain Management at home
Pain Assessment
Educate regarding nonpharmacological measures
Ice Packs
Sitz bath
Administer Tylenol or Ibuprofen
Nursing Assessments for DVT (8)
Erythema Low grade fever Swelling and pain in lower extremities Asymmetry Diminished pedal pulses Homan's sign Unilateral leg pain Dependent edema
Nursing Assessments for PE
Pleural chest pain Pink frothy sputum Tachycardia Anxiety/apprehension Dyspnea Tachypnea Fever
Post-partum blues
first 2 weeks postpartum
Irritability, anxiety, fluctuating mood, and increased emotional reactivity due to changing hormones
Mild and spontaneous remits, not considered psyc disorder
