Post Partum Flashcards
Psychological Changes
Phases:
Taking-in: Proud of the labor and delivery and pregnancy (talks about it a lot), Needs the nurse to focus on her, Very dependent on baby care, Hungry, Cold
Taking-hold: Initiates baby care, Getting up and ready for the day, More independent
If young or first child: may question ability
Letting-go: Will be sending patient home by this time, If poor and can’t afford baby bed, take a drawer, empty it out and put the baby with some padding inside, Reorganizing thoughts and family
Promotion of Bonding: Bonding happens just might take longer for some than others, Cultural differences in bonding play a role,
Development of parental love (include dad) and positive family relationships:
Rooming-in- baby in the same room as the mother
Complete- 24/7
Partial- Nursery at night
Sibling visitation
Exception: The flu
Enface: face to face with the baby
Maternal concerns and feelings
Abandonment: during pregnancy, the focus is on her, now it’s on the baby.
Disappointment: During pregnancy think you have the Gerber baby inside and then they come out and it’s not true. Doesn’t live up to your fantasy baby.
Postpartum blues: Sets in about day 2 or 3. Occurs in 80% of all women. Due to hormone switch from a lot (placenta output), to much less. Just sad/crying without a reason. Lasts about 2 weeks.
Postpartum Depression: Anything more than 2 weeks. Can last up to a year. Need meds, therapy. Can go into postpartum psychosis (911).
Respiratory Changes
Hormonal changes relieve stuffiness
Relief from dyspnea due to the birth the lungs can expand easier and the diaphragm is more useable
Nasal stuffiness is relieved within 24 hours
C-section: turn, cough, deep breathe
Sensitivity to odors has gone away if it hasn’t already
Hormonal Changes
With delivery of placenta, drastic reduction in hormones
- In 24 hours – no hCG/hPL
- Estrol decreasing during 2nd week
- **Due to decrease in Placental lactogen,
insulin need goes down (makes more resistant to insulin)
Increase in Prolactin- helps manufacture milk
- In 7 days -progestin, estrone, estradiol up to pre-pregnancy levels
- By 12 days FSH starting to rise in order to start a new menstrual cycle
Urinary Changes
Diuresis 1st 2 days postpartum: May detect leg edema 1st day, Rapid filling of the bladder, Will be putting out more urine because you have so much extra blood in your system. Will go away within 24-48 hours.
May have difficulty voiding: Due to swelling, Epidural residual- might not feel like you need to go, Increased bladder size- baby stretches the bladder so less muscle tone, ***Can’t go longer than 6 hours after delivery without voiding
Urine more nitrogenous: Due to breakdown of uterine muscle tissue
Ureters decrease in size to normal (takes a while)
***Measure the first couple of voids: If putting out small amounts at a time: could be retention with overflow, Might need to Catheter
Bladder should return to normal within 6 weeks
Circulatory Changes
Diuresis & blood loss decrease the extra volume needed in pregnancy
Diuresis also concentrates the H&H slowly to pre-pregnany levels, Will be dilute because of the extra fluid. Will concentrate after a few days, Take H&H ***2nd day, keep an eye on it
If anemic prenatally will be more so post partum.
Will retain the high levels of fibrinogen during 1st pp weeks
Elevated WBCs x 5-6 days
Anytime you are under stress, you will have an elevation of WBC
She is also healing, which raises the WBC count
Watch for post partum infections but it’s normal to have elevated WBCs
Varicosities/hemorrhoids recede
At delivery, will have much more fluid than needed.
First time you listen, might hear a murmur. Chart this!!
High coagulation: more at risk for a DVT
Heart will return to normal position in the body. (moves up in pregnancy)
Gastrointestinal Changes
Digestion and absorption active
Bowel sound active
Stool passage may be delayed due to effect of relaxin from the placenta in the system
Mom usually has a BM by the 2nd day
Evacuation may be difficult due to perineal discomfort
May be afraid it will hurt.
Poop happens behind the perineal area
Encourage them to go so that they don’t absorb more water and get an obstruction
Decreased abdominal muscle tone
Intrgumentary/MS Changes
Skin:
Stretch marks still red, will start to change to silvery (cauc) , darker (Blacks) at 3-6 months
Chloasma/linea nigra will disappear by 6 wks
For most
Excessive oil production resolves
Hair may start to fall out
Diaphoresis (sweating)
MS
Laxity of joints/ligaments
Fall risk
Muscular fatigue/soreness
Diastasis recti ( guts and stuff come out in between “6-pack”) will indent at first & may appear bluish Modified sit-ups will help
Abdominal wall and supporting ligaments will return to prestretched condition
Waddle goes away
PUPPs (skin)
Pruritic Uticarial Papules & Plaques of pregnancy
Takes a couple of months to go away. Can happen during pregnancy or post-partum
Neuro Changes
Altered Sleep Patterns
Listening for the baby
Numbness in legs, dizziness
Safety when getting up
From epidural
***Headaches Need to be evaluated Could have PIH Spots before their eyes Headache Jerky BP Seizure
Emotions
Wide range: from laughing to crying in no time at all
Baby blues
Gaining attention span
Slow progression but will come back
Immune System
- **If Rh neg, needs RhoGam within 72 hours
- **Check before she goes home that she had this!
Rubella (measles) vaccination Nonimmune status If nonimmune, need vaccine ***Signed consent Avoid pregnancy for 1 month If she gets pregnant with the active virus, could cause a lot of problems for the abby Flu-like SS may occur
Reproductive changes
Breasts Bigger - Milk produced at 3-4 days - Transient engorgement Colostrum - High protein - Antibodies
Uterus
Will go down 2 finger space per day
Lochia
Red and thick at first
Ruba Contains uterus lining
Serum (pink/brown) along with the red
10 days: becomes white (Alba): Will continue for 3 weeks. Some say as soon as this comes, it’s okay to have intercourse.
No intercourse while bleeding
We typically say 6 weeks for intercourse
Cervix
Will remain edemetis for 3-4 months
Vagina
Stretched out, wrinkles are ironed out. Will take a few weeks for them to come back
6 to 10 weeks before normal estrogen lubrication
Decreases sexual response
Perineum Depends on what kind of delivery Sore Ovaries - 10-12 weeks for nonlactation - 12-36 for lactating
Placental site healed within 6 weeks
Multiple pregnancies and larger babies will have more afterbirth pains
Effects of retrogressive changes
Exhaustion
Weight loss 5 lbs of fluid Birth: 12 lbs Lochea- 2-3 pounds at 6 weeks Weight at 6 weeks becomes your new baseline
Progressive changes
Progressive changes
Lactation
Return of menstrual flow
Usually 6-10 weeks even if they are nursing
Vital signs
Temperature Can become dehydrated during labor which raises temp Not abnormal for a high temp Needs fluids Will probably be elevated for 24 hours ***100.4 is international fever Engorgement can also raise temp
Pulse
Go back down to your usual pulse rate
If rapid: look under the covers for blood
Turn her to her side to see blood
Respirations: no notes?
Blood pressure Depends on medications Can be elevate ***Anything over 140/90, physician must be notified Orthostatic hypotension
C-Section
Purpose:
Maternal: Herpes HPV HIV/AIDS CPD PIH Induce and fail Tumor Previous C-section Elective Placenta problem Abruption Prolapsed cord
Scheduled
Emergency
Baby: Breach Transverse lie: doctor can reposition (version) Large in size Low birth weight in distress Anomalies (2 heads) Conjoined twins Multiples
Special Considerations: Recovery from anesthesia/BR Respiratory Care Different pain med Slower moving May have special assessment of uterus More frequent VS Assess incision Watch for UTI – Catheter
Otherwise routine PP care
Feed when you hear bowel sounds
Post op: move slower, can still hemorrhage, blood will be different (brighter and not as thick because doctor goes in and gets endometrial tissue out), will have post op care (more frequent vs, check uterus from the outside do avoid disrupting the stitches), check incision, check foley for voiding, different pain meds
Post Partum Assessment
Health history Family profile Allergies Routine meds How did the labor go? Gravida Para = TPAL About baby Breast or bottle
Pregnancy profile
G/P, pertinent antepartum history
Labor and birth history
Infant data
rH negative?
H&H of baby from cord blood that was sent to the lab
Cultured the placenta to check for infection so we can know to watch baby for sepsis
Postpartal course
Infant feeding method
Laboratory data
Physical findings General appearance Systems assessment ***LOC- out of wack, look under the covers for blood Color Lochia Nutrition Frequent bp Facial edema: Could mean PIH
In addition to a general physical need to examine:
Lochia - wear gloves: Consistency, Color, Amount ***< I pad per hour, Odor, Small clots okay, Bleeding may be decreased with C-section
Uterus - Fundus
Location
Size
Height - if high have pt void and recheck
Consistency – if boggy massage (gentle)
**May express clots ONLY if fundus firm Could turn the uterus inside out
**Decends 1 finger/day
Fundal massage:
- C-section: massage from sides.
- Need to have a hand holding the fundus in place so that it doesn’t come out
- ***Do not give Methergen if they have high BP
Bladder: ***Assess for fullness, due to void – 6 hours
Subjective s/s during and after void
Monitor first few voids
Returns to normal in 2-3 days
Breasts
Softness
Lumps/bumps/sore spots: Report location to the doctor, Can put heat to it and put baby to breast (pointing towards the lump) if it’s milk build up
Need to wear a good fitting bra
No soap on nipples if breast feeding (just water)
Should be soft
Nipples should not have cracks
Perineum
Intact?
Swelling?
Color
Pain meds
Trickle of blood?: Could mean a laceration of the cervix or the vagina, Cannot fix as a nurse so call the doctor
Episiotomy/Laceration?: Sew back together or leave it?, Usually place ice packs with some pressure right after delivery
Bowel function
Bowel sounds?
BM since delivery?
Passing flatus?
Incision Repair materials Edges approximated? Redness, swelling? Drainage Odor: ***Could mean infection, ***Give methergen to squeeze the uterus to get pus out
Check legs: clonus (hyperreflexia, PIH, could seize) and homan’s
Learning Needs
Provide: Group classes, Video classes, Individual instruction
Discharge planning
- Postpartum home visits: Talk to the doctor to order home visits if you feel it is necessary, Look for food, safe environment for the baby
Mother is doing alright (depression?)
- Postpartum examination: At least 6 weeks after, Are they able to take care of the baby?, Do they have a home to go to?, Tell them about next appointment
- **Danger signs of PIH: Headache, Blurred vision, Epigastric pain, Foul odor
- **Rubella and Rhogham
PCs: Post partum (PP) Hemorrhage - Atony - Lacerations - Hematoma
Thrombophlebitis/DVT
PP infection
- Endometritis
- Wound infection
- Mastitis
Psychological Problems
Lochia
***Look at slide 32 for characteristics of loch
ID Outcomes and Plan
Prevent complications
- Encourage ambulation- prevents DVTs and helps with constipation and involution
- Adequate fluids- helps avoid constipation
- Promote uterine involution
- ***Breast hygiene – monitor and wash only with water
Promote comfort
- Prevent/alleviate breast engorgement – nurse frequently
- Perineal care (Teach self care day one!) - lacerations mean burning with peeing so have her pee and squirt the peri bottle at the same time to prevent some burning
- Prevent constipation- ambulate, fluids
- Adequate rest
Nursing Care
Relief of Discomfort:
Afterpains: most pain: large babies
Muscular aches
Incisional care: clean and dry
Episiotomy care
- Perineal exercises
- Hot and cold therapy- cold on first
- Sitz baths
