Post Partum Assessment and Care Flashcards
5 Main Physiologic Events following stage 4 of labor
- uterus involutes
- lochia is present
- breasts begin milk production
- intestines are sluggish for a few days as body redistributes fluid and abdomen is more open
- Ovarian function and menstruation return
How long does uterus involution take?
6 weeks
How long until ovarian function and menstruation return in non-lactating mother?
6-12 weeks
What does BUBBLERS stand for?
8 point PP assessment
1. breast
2. uterus
3. bladder
4. bowels
5. lochia
6. episiotimy/perineum
7. reaction
8. signs
When is colostrum vs milk produced?
colostrum: later stages of pregnancy
milk: 3rd day pp
When should baby be put to breast?
First hour
Signs of mastitis
red streaks, red spots, sore, warm/tender spot, malaise if systemic
What should a non-breastfeeding mother be taught?
Avoid stimulation of the nipples
- tight bra to prevent milk from filling ducts
- cabbage/something cold to constrict blood flow
What is uterus involution?
rapid compression of uterus to non pregnancy state
sealing off of placental site
What are patients at risk for if involution does not occur?
PP hemorrhage
What impedes uterine involution?
- overextension of uterus (twins, large BW, polyhydraminos, multiparous)
- long labor/oxytocin induction
- retained placental fragments
Why would an oxytocin induction impede uterine involution?
The uterus is used to having the oxytocin promote contractions; without it, it may not contract
What enhances involution?
- oxytocin with anterior shoulder
- fundal assessments/massage
- uncomplicated birth
- complete placental expulsion
- breast feeding
- early ambulation
Boggy uterus
a finding upon physical examination where the uterus is more flaccid than would be expected.
What is a boggy uterus associated with?
Uterine atony
What is uterine atony
occurs when your uterus doesn’t contract (or tighten) properly during or after childbirth. It’s a serious complication that can cause life-threatening blood loss. Uterine atony (or the muscular tone of your uterus) describes a uterus that is soft, or lacking tone.
INVOLUTION NOT OCCURING
During a PP fundal assessment, within 12 hours where should the fundus be and what is not normal?
At or below umbilicus; above umbilicus is not normal
What type of palpation must be used for PP fundal assessment?
Deep
What three things are you assessing in PP fundal assessment
- position
- firmness
- midline
What would cause uterus to not be midline during PP fundal assessment?
bladder can displace uterus left or right impeding ability of uterus to go where it wants to go; assure it is empty
What can the massage/stimulation associated with PP fundal assessment cause?
Contraction/increased involution
Describe the anticipated progress of fundal involution day to day
Height of the fundus about one finger breadth below umbilicus (approx. 1cm) each day
Are you concerned if at at day 4 the fundus is 7 cm below umbilicus?
No
Can be involuted more quickly AT OR BELOW; only concern is decrease in rate
What are afterpains?
Involution contractions in multiparous women associated with breastfeeding due to oxytocin increases contractions
What does pain during PP palpation of fundus indicate?
Not contractions, may indicate infection
When should you administer pain medication to a breast feeding women to decrease afterpains?
1/2 hour before or PRN
What is diastasis recti abdominis?
occurs when the rectus abdominis muscles (six-pack ab muscles) separate during pregnancy from being stretched
What is the tupler technique?
The purpose of the program is to heal the weakened connective tissue between the separated abdominal muscles.
Consists of elevator exercise, contraction exercise, and head lift exercise
What is the webster techniques?
a chiropractic method used during pregnancy to address issues related to pelvic alignment. It involves specific adjustments and manipulations aimed at reducing pelvic misalignments and tension in the ligaments and muscles. By promoting optimal pelvic balance, the Webster Technique may help alleviate discomfort and potentially contribute to a smoother and safer childbirth.
Do you need to perform fundal palpation for a c-section/tubal ligation mom?
May or may not assess fundus post-op; belief was increased risk and pain
If not palpating fundus, how can we assess bleeding risk in c-section moms?
- vitals
- lochia
- pain
- risk factors
True or false: the risk of PP hemorrhage is increased in C section moms
false: Risk of hemorrhage is less because uterus is completely emptied in surgery
Pain not associated with incision in c-section mom is associated with
infection or bleeding
Capacity of bladder PP
Increased
Sensation of bladder PP
decreased
What are PP moms at risk for related to their bladder?
Urinary retention related to swelling/bruising, leading to UTI and deterring involution
When is spontaneous bowel movement anticipated PP?
2-3 days
When does elimination return to normal PP?
Within 1 week
When is lochia rubra expected
days 1-3
Describe colour, odour, consistency of lochia rubra
dark red venous blood, stale odour, clots < loonie
If lochia rubra persists following day 3 or returns, what may it indicate?
Sub-involution; blood still being transmitted through placental system
Describe lochia serosa
Days 3-10 - pinkish brownish
Describe lochia alba
Days 10-24 - yellow to white, lasting 6 weeks
1st degree perineal laceration
superficial perineal tissue torn
2nd degree perineal laceration
perineal muscle torn
3rd degree perineal laceration
perineal muscles and anal sphincter torn
4th degree perineal laceration
perineal muscles, anal sphincter and rectum torn
Describe abnormal lochia
- foul odour
- clots larger than placenta
- heavy flow
- reappearance of rubra
- lasts longer than 4 weeks
Describe the progression of normal lochia/vaginal flow
stage 4: heavy flow expected
progression from 1 pad/hr, moderate <6’, light <4’, scant <1’
What increases vaginal flow
ambulation and breastfeeding
Why do hemorrhoids occur
presentin pregnant or develop with pushing
What are interventions for hemorrhoids?
ice, frozen pad, tucks (OTC pads of cotton with witchhazel), analgesic
Why do hematomas occur?
soft tissue of perineum offers little resistance and can readily accumulate 250-500mls of blood
What can prevent hematomas?
Early application of ice
What is a cardinal sign of hematoma
relentless pain
Normal pad saturation on first day post partum:
1 pad/hr
Besides assessment, what other nursing interventions regarding the perineum can occur?
perineal care and education on perineal tone
First phase of reactions post partum
taking in - day 1-2
- preoccupied with own needs and recovery tell story
- touches and explores infant
Second phase of reactions post partum
taking hold - day 2-3
- ready to resume control
- eager to learn
- rapid mood swings
- mothering functioning established
Third phase of reactions post partum
letting go
sees infant as unique person, allows others to care
Describe the initial attachment behaviour post partum
holds infant in en face position: (non-birthing parent/dad), face-to-face position about 20cm, same plane; mother uses soft, high-pitched voice
what is the en face position
direct face-to-face and eye-to-eye contact between the mother and newborn. When the newborn’s eyes are open, the mother instinctively greets the newborn and talks in high pitched tones to him or her.
When do baby blues typically occur and resolve
first 3-5 days PP and resolves spontaneously within weeks
What contributes to baby blues?
Decrease in estrogen and progesterone levels; hormonal change as contribution, as well as time of increased stress
Describe the symptoms of baby blues
Tearfulness, agitation, mood swings, generalized anxiety, acute disturbances in appetite and sleep, a perception of being overwhelmed and uncertain, and irritability
True or false: baby blues are a part of the perinatal mood disorder spectrum
False
Care for baby blues
recognition, reassurance, education, awareness of blues as a risk factor for postpartum depression
What are the post partum pinks
Mild elation/euphoria hours/days after birth
Normal but may also be a warning for other problems
_______ % of those with baby blues will develop post partum depression
20
What is the edinburgh postnatal depression scale screening tool?
a simple questionnaire used to screen for signs of postpartum depression in new mothers. It consists of 10 questions that assess a woman’s mood, feelings, and emotional well-being during the postpartum period. Higher scores on the scale indicate a greater likelihood of postpartum depression, prompting further evaluation and support for the mother.
____% of patients and _____% of partners experience PPD
1/7 moms 1/10 partners
What signs are important to consider post partum?
Vital signs
Signs of pain
Signs of DVT r/t hypercoaguable state and decreases mobility
- pain, pulse, pallor, paralysis, paresthesia
What additional assessments need to be performed on a c-section postpartum mother?
- foley (ins and outs)
- IV
- DB and Coughing
- Early ambulation
- Sedation Score
- Analgesia
Outside of bubblers, what other assessments are performed for post partum mothers?
- Rh negative
- Rubella
- HgB
- Nutrition
If baby is Rh positive for an Rh negative mom, what occurs?
Mom may get WinRho (RhoGAM) within 72 hours of delivery
What vaccine is offered PP and what should you advise patients on?
Rubella; not to get pregnant for 3 months
When is HgB tested post partum?
1 day pp r/t anemia due to blood loss
What education must you provide a BF mom post partum regarding nutrition?
At least 200 calories more than pregnancy diet
Reoccurence of ovulation/menstruation in non-lactating moms
6-8 weeks; delayed but not reliable form of birth control
True or false: a BF mom will experience her period and return of menstruation faster than a non BF mom
False
Prolactin suppresses ovulation
When can PP patients engage in sexual activity?
wait until lochia has stopped and perineum has healed
typically 3-6 weeks
What contraception is recommended as safe for breast feeding and why?
Progestin only
No estrogen related side effects
-Contraceptives which contain estrogen have been linked to reduced milk supply and early cessation of breastfeeding even when started after milk supply is well established and baby is older
Decreases VTE risk
Why is combination estrogen/progestin not recommended until after 6 weeks?
Increased VTE risk
What is tubal ligation?
permanent female sterilization done laproscopically as outpatient
True or false: you palpate the fundus following a tubal ligation procedure
False; or very gently if needed
4 most common PP complications
- hemorrhage
- infection
- depression
- DVT
What symptoms regarding vaginal flow PP would you report?
foul smelling, heavy flow, clots
What symptoms regarding temperature PP would you report?
chills/fever T>38
What symptoms regarding pain PP would you report?
constant in lower abdomen
What symptoms regarding urine PP would you report?
Pain, burning, urgency or difficulty passing
What peripheral vascular system symptoms PP would you report?
Redness / swelling / pain in leg
DVT
What respiratory changes PP would you report?
Unexplained shortness of breath or chest pain
What CNS related changes PP would you report?
headache, vision changes, fainting, dizziness
Why would you report tender red area in breast with flu-like symptoms?
Signs of mastitis
PP Client outcome criteria: ______ Hemoglobin with no _____________
normal, fainting/dizziness
PP Client outcome mobility
satisfactory ambulation
PP lochia client outcome criteria
decrease colour and amount by day 3-5 no foul odour
PP Client outcome uterus
firm, midline, contracted
PP Client voiding criteria
at least 1 void prior to discharge without dysruia
PP Client breast criteria
soft/supple nipples
soft: day 1-2
filling: day 3-4
fullness evident
engorgement controlled
What is breast engorgement
a condition where a new mother’s breasts become overly full, swollen, and painful due to an accumulation of milk
