post-partum (unit 2) Flashcards
uterus involution
•uterus returns to pre-pregnant size/shape
•causes sharp afterpains (ct.)
•lowers 1 cm/day
•by PP day 10, uterus within pelvis and non palpable
*WNL at 4-6 weeks pp
lochia-discharge
- Rubra- birth-PP 3
- Serosa- PP day 4-10
- Alba (yellow)- PP day 11-wk 6
Why might a patient
“gush” blood upon
standing up from a
supine position?
- blood may have pooled in the vaginal vault while the patient rested in a supine position
- also have some clots
- As long as the increased flow resolves and the patient’s uterus is firm and ML, she is ok
cervix PP
- immediately post SVD, wide enough for hand
- after 1 wk- pencil eraser
- external os from round to slit
- possible lacerations
vagina PP
- immediately post SVD- edematous w/ rugae
- after 6 wk- pre-preggo size
- atrophic until menses resumes
- lacerations possible
dyspareunia
- dryness and itching of vagina
- r/t declining estrogen levels b/c diminishes lubrication
- esp. common in BF b/c prolactin antagonizes estrogen
perineum PP
- edema/bruising
- lacerations (1-4 degree)
- episiotomy
- lacerations
1st degree perineal laceration
•extends thru skin/structures to superficial muscles
2nd degree perineal laceration
•extends thru muscles of perineal body
3rd degree perineal laceration
•extends thru anal sphincter muscle
4th degree perineal laceration
- involves anterior rectal wall
- rare
- require more intervention
perineum discomfort tx
- ice for first 48 hrs
* then sit baths bid
estimated blood loss (EBL)
•lose 500cc blood SVD
•lose 1000cc blood C/S
•also lose blood volume when diaphoresis/diuresis PP
*orthostatic hypotension common
what does declining estrogen levels PP cause
- no lubrication of vagina
* diaphoresis
why don’t mom’s go into hypovolumetric shock during delivery?
- blood flow to placenta diverted during delivery
* rapid reduction in uterine size
cardiac output PP
- elevation of pulse, SV, and CO for first hr
- gradual decrease to prepreggo
- brady common 1-2 days PP b/c dec. blood volume (trying to maintain CO)
- if tacky check for infection
- baseline by 8-10 wks
coagulation PP
•hypercoagulated in pregnancy and PP for 2-3 wks b/c have increased fibrinogen
**risk for DVT for up to 6 months
labs PP
•elevated WBC (25,000) for 2 wks •H&H hard to assess and only addressed if hct <18 and symptomatic -dizzy -pallor -weak
GI PP
•constipation
•BM incontinence if operative vaginal birth
•hunger
•thirst
*keep NPO until sounds, then clear liquids until flatus
why constipation PP
- inc. progesterone slows peristalsis
- long NPO
- painful BM from trauma
why hunger/thirst PP
- long NPO
- large energy expenditure
- early diuresis
urinary system PP
•excessive diuresis w/in 2 days (3000cc/day) •r/o distended bladder d/t -dec. tone -trauma -diuresis -anesthesia (epidural -> retention) *high risk for UTI/postpartum hemorrhage
musculoskeletal PP
- aches/pains/fatigue
- relaxin WNL w/in few days, but can cause early hip pain
- diastasis recti possible
musculoskeletal 6-8 wks PP
- joint return to normal
- feet permanently enlarged
- muscle tone restored b/c progesterone dec.
integumentary PP
- melanin dec. -> linea nigra, chloasma fade
- estrogen dec. -> palmar erythema, spider nevi fade
- striae gravidarum fade to silver (never go away)
endocrine PP
- menses w/in 4-6 wk (if not BF)
- ovulation before menses so BC crucial
- estrogen, progesterone, HPL, HCG decline
- prolactin decline at 3 wk if not BF
- resolution of GDM
why does prolactin delay menses/ovulation
- suppresses the release of LH and FSH
* still need BC
what causes lactation
- rapid falling levels of estrogen and progesterone
- increasing levels of prolactin
- increasing oxytocin (let down)
weight loss PP
•12 lbs at delivery
•8-9 lbs at 2 wks
•pre-preggo at 6 mo-yr
*BF slower loss of adipose tissue INITIALLY
initial PP assessment
- begin 4th stage
- frequent VS, fundus, lochia
- pain
- IV site/patency
- bladder
- LE movement
VS 4th stage
- q15min x 4 hr
- q30min x 2 hr
- qhr x 2 hr
- q4-8 hrs
BUBBLE HE
- breasts
- uterus
- bladder
- bowel
- Lochia
- Episiotomy
- Homan’s sign
- Emotions
PP breast assessment
•soft, nontender first 2 days
•firm/lumpy/fuller 72-96 hrs b/c colostrum mature milk
*s/sx fullness subside w/ BF
PP uterus assessment
- have pt void first
- massage/expel clots
- provide meds if needed (Pitocin, methergine, cytotec)
u/1,2… (u-1,2…)
- fundus below umbilicus
* how many fingers below (subjective)
1,2…/u (u+1,2…)
- fundus above umbilicus
* how many fingers above (subjective)
problem w/ distended bladder
•uterus elevates to R
•uterus can’t ctx/drain
•uterus retains lochia and can cause excessive bleeding
*can’t DC if < 30 cc/hr
PP lochia
•constant trickle dangerous (MD)
•excessive amnt w/ ctx indicates unrepaired laceration (MD)
•foul smell could be infection (tenderness/temp/tachy)
*goal < 1 pad/hr
PP episiotomy/incision assessment
R- redness E- edema E- ecchymosis D- discharge A- approximation *indicates infection IF accompanied by pain
LE assessment PP
- edema/varicose veins possible
* DTRs should be 1+ or 2+ b/c brisk hyper reflexes indicates pre-eclampsia
dec. BP PP could be…
- dehydration
* hypovolemia
inc. BP PP could be
•pre-eclampsia
*compare to admission BP
tachycardia PP
•could b from excitement, fatigue, dehydration, hypovolemia
•check fundus, lochia, CBC
•may be early s/sx of shock
*brady would be from blood vol. dec.
temp. PP
- elevated up to 100.4 expected first 24 hr
* if 100.4 or > for more than 24 hr, notify MD
promoting comfort PP
- assess/tx pain
- 3000cc fluids/day
- regular diet
- adequate rest/sleep
Rhogam PP
- given if mom Rh- and baby Rh+
* given w/in 72 hrs
Kleinhauer-Betke
•drawn w/ CBC PP to determine ant of fetal blood in maternal circulation
*if > 15 mL, increase Rhogam
MMR vaccine
- all child-bearing should have, esp. if non-immune
- DON’T become preg for 1 month
- Rubella during prig devastating for fetus
breast care for lactating mom
- avoid soap/lotion to nipples
- feed baby on demand
- keep nipples dry (pat)
- use lanolin for nipple trauma
- good support bra
- cabbage leaves/ibprofen/ice for engorgement (ONLY BF mom cam pump)
kegal exercises PP
- will strenghten perineal muscle
- tighten muscle (stop urine), hold 10 sec, relax
- do 5 times daily
PP danger signs to report to MD
- fever > 100.4
- localized breast edema (esp. w/ flu s/sx)
- persistent abd tenderness/pelvic pressure
- persistent perineal pain
- UTI
- lochia change
- DVT s/sx
criteria for D/C
- free of infection s/sx
- able to void > 30cc/hr
- fundal ht/lochia WNL
- H&H WNL
- Rhogam/rubella vaccinated
- educated on danger signs
- mom able to reach HCP in emergency
bondings
- developed by attachment and physical contact b/t parents and infant
- love and acceptance
- enhanced in 1st hr of life
- maternal touch is key
early post-partum hemorrhage
- occurs w/in 24 hrs after delivery
- vaginal: > 500cc blood loss
- C/S: > 1000cc blood loss
- caused by uterine atony or trauma r/t laceration
risk factors for PP hemorrhage
- uterine atony
- placental complications
- precipitous delivery
- MgSO4 therapy
- laceration trauma/hematomas
- inversion of uterus
- sub involution of uterus
- retained placental fragments
- coagulopathies (DIC)
causes of uterine atony
- overdistention (multi GA; tumor; polyhydranious; big baby)
- multipartiy
- tocolytic drugs (rlx uterus)
- prolonged/precipitous (rapid) labor/delivery
- C/S
- induction
signs of early PP hemorrhage
- excessive lochia
- fundus soft/difficult the locate
- fundus above expected level
early PP hemorrhage tx
- fundal massage (tx for uterus)
- ABCs
- start new (lg. bore) IV for fluids
- admin meds/blood
- elevate legs (tx for shock)
meds for early PP hemorrhage
•O2- 2-3 L NC to inc. RBC sat •oxytocin •Methergin IM- inc. froce/freq. ctx -contra in HTN •carbopropst/cytotec rectal- smooth mscl. ctx •Hemabate IM •Hespan- vol. expander (colloid)
anticipated action for PP hemorrhage
- OR
- D&C
- uterine packing/Bakri balloon
- hysterectomy
- ICU
shock
- complication of early PP hemorrhage
* vasoconstriction -> blood shunted to vital organs (heart, lungs, brain)
RN protocol in emergency for PP hemorrhage
•Labs (H&H; T&S) •pusle ox •foley •O2 by ventimask •add. fld./lines; blood products *autonomy when MD not present
RN initial interventions PP hemorrhage
- call for help
- fundal massage
- bolus Pitocin
- continuous pulse Ox/VS
- reverse trendelenberg
- change pads, so can observe
- calm pt/fam.
- privacy
hematoma
- 250-500cc of blood collects in tissues in vulvar, vaginal, retroperitoneal area
- may present as bluish mass
- caused by laceration, but occurs behind it
- severe rectal pain/pressure (normally)
- s/sx concealed blood loss
- trauma that can lead to early PP hemorrhage
laceration of birth canal
- bright, red bleeding w/ firmly contracted uterus, midline at expected level
- trauma that can lead to early PP hemorrhage
late PP hemorrhage
- > 24 hr PP, but less than 2 wks PP
* caused by subinvolution
subinvolution
•uterus remains enlarged w/ continued local discharge
subinvolution causes
- retained placental fragments
* endometritis (pelvic infection)
s/sx subinvolution
- prolonged, foul-smelling, excessive lochia
- hemorrhage
- pelvic pain/heaviness
- backache
- malaise
- fatigue
- large/soft uterus
subinvolution tx
- methergine- ctx.
- abx
- D&C last resort when methergine/abx not working
thromboembolic disorders PP
- major cause of maternal death
- 5x greater occurrence in prig and PP than non-preggo
- 3x more likely w/ C/S
causes of thrombosis in childbearing women
- venous stasis
- hypercoagulable blood
- vessel injury
risk factors for thrombosis
- varicose veins
- smoking
- obesity
- hx of thrombophlebitis
- clotting disorders
SVT
- in calf
- swelling/erythema
- tenderness/warmth
- lg hard vein
- pain w/ walking
DVT
- little/no s/sx
- calf swelling/warmth/erythema
- tenderness
- pedal edema
- pulses unequal
- venous doppler dx
prevention of thrombosis
- ambulation
- range of motion
- avoid pillows under knees
SVT tx
- support hsoe
- rest
- analgesics (NO ASA or ibuprofen)
- elevate affected leg
DVT tx
- IV heparin
- bedrest
- elevate
- analgesics
- Coumadin
- monitor coags
- gradual ambulation
- DONT massage
endometritis
- 2-5 days PP
- inflammation/infecton of endometrium
- can spread, causing sepsis and sterility
s/sx endometritis
- fever/chills
- tachy
- lethargy
- malaise
- anorexia/nausea
- abd/uterine pain
- foul, purulent lochia
endometritis tx
- IV abx
- analgesics
- comfort
- prevention
- high fowlers to drain lochia
UTI
- cystitis, urethritis
- dysuria/diuresis
- tx w/ abx and cranberry juice
- 300 mL fld./day
PP wound infection
- most common PP infection
- episiotomy, vagina, C/S incision
- s/sx of REEDA
PP wound infection tx
- I&D (incision & drainage)
- abx
- analgesics
- remove staples/suture
- pack
- sitz bath/warm compress
- freq. peri-care
- inc. flds
mastitis
- infection of lactating breast
- doesn’t occur w/in first few days b/c skin still in tact and no milk yet
- more common in first BF mom
- one breast ONLY
mastitis causes
- bacteria (staph) enter injured nipple
- insufficient breast emptying
- engorgement/stasis
s/sx mastitis
- flu-like
- chills/fever/malaise
- HA
- localized red/inflam/tender
mastitis tx
•abx •bedrest initially •3000cc fld/day •ice •analgesics •BF (safe) unless abscess forms or too painful (pump) •warm shower (dilation) •resolves in 24-48 hr *tx crucial to avoid abscess
mastitis prevention
- empty q 2-3 hr
- no tight bra
- massage milk ducts while feeding
- inc. fld intake
- good hygiene
baby blues
- 1-2 days PP
- rarely last > 2 wks
- trouble sleeping/eating and tearful but not sad
- still joyfully care for baby
- no tx needed
PP depression
- 4 wks- 6 months PP
- s/sx depression > 2 wks
- persistent sadness/mood swings
- no joy w/ infant care
- tx w/ psychotherapy, meds, ECT
PP psychosis
- severe psychotic state
- confusion
- disorientation
- AH &/or VH
- delusion
- obsessive behavior
- paranoia
- self/infant harm
- tx w/ aggressive IN pt hospitalization
the bigger/more stressed the uterus…
•the worse the afterpains b/c has to work harder to get back to normal •d/t -multiple babies -big baby -fibroids (benign tumor) -uterine problems
important RN measures
- check IV and assess what have/should be hanging
* ensure the foley bag below bladder
intervention for deviated fundus PP
- help to bathroom
- if can’t urinate use running water, warm perineal, hands in water, sitz bath
- in/out cath as last resort
lochia assessment PP day 2
- rubra/serous
* scant
if hemorrhage from laceration trauma, uterus is…
•firm b/c laceration doesn’t involve the uterus, so it would be normal for PP
*firm uterus w/ bleeding is
s/sx hypovolumetric shock
•earliest sign is tachycardia •BP inc. initially, then dec. after ⅓ vol. lost •RR inc. to get O2 to organs •skin cool, clammy, diminished cap refill •pallor •tachycardia •hypotension •N/V •dec. UOP *elevate legs
causes of concealed blood loss
- broken stitch
* hematoma
meaty clots
•from uterine atony
thin/shiny clots
•from trauma
tocolytic drugs
- MgSO4
* terbutaline
trauma causes
- large baby
- operative vaginal delivery
- soft part abnormality
- rapid delivery
uterine atony tx
- fundal massage
- bolus Pit.
- meds
trauma tx
- call MD
- ice
- pressure
- tx shock if occurs
hypovolemic shock tx
•trendelberg/elevate legs •O2 •2nd IV/fluids •admin expanders •ABCs *both uterine atony and trauma ultimately lead to shock
uterine atony last resort tx
- D&C
- hysterectomy
- packing
trauma last resort tx
•repair
when to start worrying about PP infection
- if > 100.4 w/in first 24 hrs
* if 100.4 or > for more than 24 hrs
RN action if pt calls w/ breast pain
- ask if both or one breast
- mastitis is normally just one breast
- engorgement is both
