Postnatal woman Flashcards
MBAUBBLES
Post natal assessment Mind Breasts Abdomen Uterus Bowels Bladder Legs and loss Episiotomy Support
Mind
Assess-
Emotional- feelings
Physical- pain
Bonding/attachment
Also education- take home brochures websites
What women should be carefully monitored in PN ax
CS Episiotomy Pre eclampsia Assisted birth Epidural
What symptoms need further investigation if found
Swelling Uterus not involuting Headaches High BP Visual disturbances
Breasts
Looking for Symmetry Tenderness Swelling Redness Pain Attachment Ask- full, tender, soft, firm Nipples Palp
Also education- expressing, signs of infection, discuss on demand, reassure first attachment might be painful, tender milk trying to come in, how to express, changing sides
Abdomen
Diastasis recti
Separation of abdominal muscles more than 2 cm
Advice- refer to physio, limits, safety, supportive bands, high fibre, mobility, pain mx
Signs and symptoms of diastasis recti
Palpable
Back pain
Bladder issues
More common in grand multi
Uterus
Ax the uterus is contracted, tender, bilateral Monitoring blood loss Pain level- tender on palp? Location below umbilical Involution
When is it normal to have increased loss
Assisted birth CS Prolonged labour Grand multi Full bladder
Aims of postnatal care
Support attachment /bonding Support into transition into parenthood Observe risk of PPH and infection Education- attachment, SIDS, sick baby signs, PPH, bf, pelvic floor exercises Dvt prevent Good maternal child relationships
Causes of PPH
Four Ts Tissue (retained) Trauma (tear) Tone (uterus) Thrombin
When does a secondary PPH occur
24 hrs to 6 weeks postpartum period
Caused by four Ts
Education: how monitor for PPH
Pads to monitor loss Colour Consistency Amount Resources Or do hb
Normal bladder freq and vol
Void post VB - 1-2 hrs Max tolerance 6 hrs 8 times in 24 hrs Normal bladder vol is 200-400 Postpartum is a large void Every 3 hrs
Why must we wait 6 hrs post epidural VB or 12 hrs epidural CS to remove IDC?
Sensation must return so we can ensure they are retaining fluid
Risk factors for bladder retention
Epidural Should dystocia Prolonged 2nd Forceps CS
Bladder concerns
Small and freq Uterus higher than last checked Feels full No sensation when going Incontinent
Void questions
Colour
Amount
Pain
Odour
Urinary incontinent mx
Fluid intake increase
Early ambulatory
Mobility
Warm shower
Bowel
Questions Info Assist Hemorrhoids Further investigation
Bladder
Discuss freq Vol IDC Risks Concerns Ask Mx for incontinence
Education: bowels
Fibre and diet Pressure on perineum to protect wounds Hemmorrhoids common Constipation common first 2 days Early ambulation aids
Bowel assessment questions
Constipation? Urge? Normal for them Amount Consistency Colour
How could you offer to assist constipation
Fibre supps
Stool softener
Reassure
Pharmalogical mx for hemorrhoids
Paracetamol
Cold compressors
Topical ointment
Further investigation of bowels
Long period of time Abdomen discomfort On continence Swilled hemorrhoids Bleeding
Loss/legs
Lochia changes
Conditions of L&L
Three types of lochia
Rebra
Serosa
Alba
Lochia rubra
DAY 1-3 Blood Amnion Chorion Decidual cells Vernix Languo
Lochia serosa
DAY 4-10 Blood Wound excudate Erythromycin Leucocytes Cervical mucous Microorganisms
Lochia alba
DAY 11-21 Leukocytes Decidual cells Bacteria Epithelial cells
Life threatening conditions to do with loss and legs
Haematoma & abbess formation
Infection- sepsis
Pulmonary embolism
S&S pulmonary embolism
SOB- blood clot that enters lungs
Episiotomy
Assess- visual Pain Swelling or excudate Mx for pain Perineal care Referrals 3rd 4th
Perineal ax
Visual- swelling, gaping, bulging, bruising, discharge, odour, bleeding, healing tissue
May not need to visualise- ask if pain/tender or swelling or excudate
Pass urine without sting?
Pain relief?
Infection- excudate, temp, heat
Management for perineal pain
Ice
Analgesia
Hygiene
Educate; perineal care
Empt bladder fully and often Ice packs Mobilise High fibre Stool softeners Refer to gyany or obst if 3/4
Support
Mental health PND Ax supportive network Access to services Domestic violence Signs and symptoms Puerperal psychosis Resources
Assess for PND
Supportive network Mental history Access Violence Secure housing
Signs of maternal mental illness
Disinterested No binding Left in cot Mood Sleep disturbance Overwhelmed Family reports
Puerperal psychosis signs
Manic or depressive Euphoria Grandiose Delusions Hallucinations
Main Physiological changes in peurperium
Involution
Decreased blood vol
Muscle and ligaments return
Secrete milk and establish lactation
Physiological change systems
Cvs Resp renal Gastrointestinal Endocrine
Following delivery of placenta what hormones decrease
HPL
HCG
Oestrogen- 7 days
Progesterone -24-48hrs
Prolactin is secrete by the – and — during pregnancy
Anterior pituitary gland
Increases
Why does the decrease in oestrogen stimulate bf
Because oestrogen antagonises prolactin and it’s reduced after birth
Oxytocin is produced by the – and stored in the –
Hypothalamus
Posterior pituitary gland
Role of oxytocin
Stimulates electrical and contractile activity and acts on myomere kin of uterus, assisting in ejection of milk and uterine involution
Uterine involution
Free placenta birth
Contracts causing apposition of uterine walls
Haemostasis controlled by contraction
Blood clotting activateda fibrogen and platelets
Oxytocin leads to contractions and further retraction
By day 7 uterus has
Halved to 500g, by end of puerperium 60g
After pains
Intense
Diminish 4-7 days
Increase dying bf bc oxytocin helps release milk but also increases contractions
Decidua
Uterine lining
Physiological steps of uterine involution
Vasoconstriction- muscle fibres squeeze off BV where placenta sep - ischaemia
Auto lysis - auto digestion of muscle fires by enzymes
Phagocytosis - removes excess fibres and tissue
Rate of involution.
1cm per day Should always progress not digress Below umbi Day21- should return to pelvic cavity No longer palpable above Punic bone
Decidua is shed as
Lochia
Endometrium
Mucous lining
Innermost layer
Regeneration occurs rapidly - basal layer in 10 days
Changes in cervix
Immediately- soft and vascular Rapidly converts to PPS firm Shortens Firmer Internal os closed 2 week External os open for some months
Decreased progesterone after
Recovers normal
Muscle tone
Cardiovascular changes
BV loss (haemodilution no longer req) Diuresis- oestrogen CO, SV increase- return of blood to maternal system BP maybe Lower Decrease in cardiac workload Dec circulatory vol 02 demands dec return to normal Blood co2 levels return to norm Clotting factors increase fibrinogen Haemoglobin increase
Respiratory changes
Because Decrease size of uterus, decrease excess tissue and circulating fluid
= dec in pressure of maternal lungs- able to fully inflate inc basal lobes
GIT changes
Return:
Tone smooth muscle- dec progesterone
Carb metabolism- appetite increase, heart burn dec, constipation dec
Insulin- 48hrs-6wks bc dec oestrogen
Renal changes
Less need for renal bf Progesterone dec= less renal dilation Size and shape return Bladder displaced, urethra stretched Loss of tone in bladder
Loss of tone in bladder + bruised urethra + Diuresis =
Become over full and distended = retention
Describe head to toe approach of PN ax
See notes
Bp reruns to pre pregnant state - hrs after
24
Abdominal musculature
Ax of long muscles of abdomen PN to identify diastasis rectis abdominis
Direct combs test
Test for Rhesus factor
Fetus checked for need of anti d by cord blood
Cligh howers test
Test for Rhesus factor
Tests number for feral cells in maternal system
3 categories of thromboembolism
Superficial thrombophlebitis (veins) Deep vein thrombosis (calves thighs) Pulmonary emboli (chest pain tachy)
Superficial thrombophlebitis
Superficial veins
Mx
Supportive bandage
Elevate
Deep vein thrombosis
Deep veins of calf and thigh
One side
Pain redness swelling one leg
Pulmonary emboli
Sob Chest pain Dyspnoea Cough Crackles Hypo
Why is thromboembolism more likely to occur in puerperium
Large diuresis
Resolution of haemodilution
Muscles of perineum
Series of longitudinal and round structures
Deep layer PII
Superficial layer TIV
Circle layer
Deep layer of perineum
PII
Puboccocygeus
Illiococcygeus
Ischiococcygeus
Superficial layer of perineum
TIV
Transverse perineal muscle
Ischocavanus
Vulvocavanous
Circle layer perineum
Assists with opening and closing orrifices
Ax of perineal healing
Asking about pain Passing urine Bowels Examine Educate
Perineal care -HIPPS
Hygiene Ice Pelvic floor exercises Pain relief Support
Pharmalogical consideration for 3/4 deg
Analgesics Anti inflam Oral abs With stool softeners and bulking agents Ibuprofen pest choice with rectal disclofenac (epis)
Long term morbidities perineal trauma
Infection Haemorrhage Fistula Haematoma Incontinence Pain
Pain relief for CS
PCA Epidural NSAIDs Narcotics If IV infusion- freq observe resp, sedation, pain
Wound care CS
Observe for bleeding, discharge, infection, pain, redness, separation/ dihiscence, heat, swelling
Remove sutures as ordered
Wound drainage
Record amount type
Remove as ordered
IDC removal not before 12 hrs of top up epidural
Record first voids post removal
Complications of CS
PPH
Infection- wound, endometrium, IVT, UTI from IDC
Thromboembolism- less mobility more blood lose
Epidural- hypotension Duran tap (dura punctured - headache unrelieved by meds)
