Postpartum

Question 1

When does a low grade temperature change happen?

Answer 1

This is a temperature under 100.4
This is common when milk starts to “come in”
This can happen SECONDARY to dehydration in the immediate postpartum period

Question 2

What does a temperature above 100.4 indicate?

Answer 2

an infection

Question 3

Endometritis

Answer 3

1. an infection developed in the uterus during labor

2. endometritis is a secondary infection of the uterus

Question 4

What increases the risk of developing an infection in the uterus/endometritis?

Answer 4

If the water has been broken for > 24 hours

If the woman had a c-section

Question 5

S/S r/t blood loss (or infection)

Answer 5

Elevations in the pulse and temperature rates can be related to blood loss or infection
SOB and syncope are indicators of SIGNIFICANT blood loss

Question 6

What lab results do you look at to assess blood loss?

Answer 6

HCT and HGB

Question 7

Review of rubella status and administrating the vax if _____ or _____

Answer 7

if negative or equivocal
this is a LIVE vaccine, it is important that the mother not get pregnant for the next 3 months
the live virus can then cross the placenta and effect the pregnancy

Question 8

rh status and administration of rhogam

Answer 8

if the mother is Rh negative and the infant is Rh positive
Rhogam helps to prevent the mother’s blood from developing antibodies against positive blood types
Subsequent pregnancies are affected - antibodies cross the placenta barrier and effect babies blood cells

Question 9

Postpartum

Answer 9

starts at the delivery of the placenta and continues for approximately 6 weeks as the reproductive organs return to their normal non-pregnant state
the new mother must put her birth experience into perspective and transition into the role of caregiver for her new infant
education related to self care and infant care are important components of postpartum care

Question 10

Immediate postpartum changes

Answer 10

• uterine involution
• cervical involution
• lochia flow
• decrease in vaginal distention
• breast changes
• urinary changes
• GI changes
• CV changes
• endocrine changes

Question 11

Uterine involution

Answer 11

uterine is contracting down until it goes back to pregnancy size
starts at delivery but continues through postpartum period
the uterus continues to contract after delivery… the dilated blood vessels flow through the muscles fibers of the uterus
as the uterus contracts its like a tourniquet effect
these contractions are called “after cramps” and are more noticeable the more pregnancies a women has
VERY IMPORTANT SO NO HEMORRHAGE
more noticeable after breastfeeding - cause contrction of uterus

Question 12

what is the number 1 cause of maternal death in the world?

Answer 12

POSTPARTUM HEMORRHAGE

Question 13

Fundus location (after expulsion of placenta and after delivery)

Answer 13

Immediately after expulsion of the placenta, the top of the fundus is in the midline and approximately halfway between the symphysis pubis and the umbilicus
About 6 to 12 hours after birth, the fundus is at the level of the umbilicus. The height of the fundus then decreases about one finger-breath (approximately 1cm) each day.
Due to coagulation and relaxation
6 to 12 hours after delivery, the highest point of the uterus, the fundus, is usually located at the umbilicus. It feels like a grapefruit in the abdomen.

Question 14

Why does the fundus height decrease each day?

Answer 14

Due to coagulation and relaxation

Question 15

Why is it concerning if the uterus is above the umbillicus?

Answer 15

uterus is not well contracted and blood flow may increase

increase the risk of postpartum hemorrhage

Question 16

What affects contraction of the uterus?

Answer 16

the more distended the uterus has been during pregnancy –> the more difficult it is for it to contract effectively after delivery
Because of this women who has had multiple infants and those who have large infants are at increased risk for hemorrhage.
A distended bladder (which displaces the uterus) can interfere with effective contraction

Question 17

What happens when the bladder is distended

Answer 17

the fundus will be above the umbillicus and displaced to the right

Question 18

Vaginal tone

Answer 18

Like the uterus, the cervix and vagina involute after delivery
These organs have dilated to allow for passage of the infant
After delivery they start to return to their normal proportions
The cervix must close to prevent infection for having access to the uterine cavity
Aerobic bacteria are part of normal bacteria of vagina
Uterine cavity is anaerobic
Like uterine involution this process takes up to several weeks
Kegel exercises assist with restoring vaginal tone

Question 19

Vaginal flow

Answer 19

Vaginal flow after delivery is usually representative of the shedding of the uterine lining and the oozing from the site of placental implantation

Question 20

Excessive bleeding can come from…

Answer 20

Uterine atony (lack of contraction)
Unrepaired cervical, vaginal, or perineal lacerations
Retained placental fragments- uterus cannot contract effectively
Vaginal or vulvar hematomas
Coagulpoathies

Question 21

Lochia Assessment

Answer 21

Initial lochia is called rubra and is red in color
The brighter red the flow, the fresher the bleeding
Darker more mahogany colored bleeding represents older bleeding that collected in the vagina and uterus and was expressed
Larger amounts of this very dark flow is especially common with position changes (1-3 days after delivery)
Lochia serousa- serousy and pinkish brown color, 4-10 days after delivery
Can be seen as soon as second day postpartum
Lochia alba- yellowy white color. It has a distinctive fleshy odor (11 days-6 weeks after delivery)

Question 22

Measuring lochia

Answer 22

Scant- < 2.5cm
Light- < 10 cm
Moderate- > 10cm
Heavy- saturating a pad every 2 hours
Excessive- saturating a pad every 15 minutes and/or pooling of blood under the buttocks
Lochia is often accompanied by blood clots

Question 23

Breast Changes

Answer 23

Can happen whether or not the woman intends to breastfeed
For the first 1-3 days after birth, breasts secrete colostrum- a dense yellowish fluid rich in protein, fat, and antibodies
Between the 2nd and 5th day, the mature milk will start to come in
The woman’s breasts may feel hard and full (potentially engorged)
When breasts are full → may feel lumpy
Ducts in the breasts are filling individually

Question 24

Ways to prevent nipple trauma

Answer 24

Breastfeeding mothers may experience nipple trauma if they are not educated on preventative measures including:
Making sure the infant latches well each time
Only on tip → force is on small surface area
Areola as much as possible in mouth
Changing start side
Most aggressive on first side (hungriest)
Changing positions
Do not wipe off secretions
The breast secretes lubrication between feedings
Air exposure after feeding (for 15-20 mins) nipples will heal between feedings
Nipples can blister and crack which impedes feeding because of discomfort and can create an entry port for bacteria → risk for developing mastitis

Question 25

Breast engorgement prevention

Answer 25

Best prevention and treatment is for engorgement in the breastfeeding mother is frequent breastfeeding For the non-nursing mother, prevention of engorgement is important The woman should be instructed to put a snug fitting bra on immediately after delivery and to continue to wear it Ice packs may be used on the breasts and raw cabbage leaves may be used to line the bra Her breasts should not be stimulated

Question 26

Urinary changes

Answer 26

Increased diuresis because of reduced estrogen (w/ passing of placenta) Fluid from third spacing comes back into vascular system and to be removed by the kidneys Increased space available in pelvis Potential for urinary retention especially in vaginal deliveries r/t swelling and birth trauma

Question 27

When is it necessary for a woman to void by?

Answer 27

8 hours ~ at least 150 cc ** if she is unable to void, she should be straight catheterized

Question 28

Bowel Changes

Answer 28

GI changes include increased motility because of decrease progesterone Progesterone- food in stomach for longer period of time, allowing for greater extraction of nutrients There is less pressure and displacement of the stomach and bowel C-section patients will have decreased motility initially. It is common practice to gradually resume feedings (to prevent a paralytic ileus) Flatus- indicative of return of bowel function

Question 29

Diastasis recti abdominis

Answer 29

a separation of the musculature, commonly occurs after pregnancy takes several weeks for these muscles to come back into proximity don't want new mothers doing ab exercises

Question 30

CV changes

Answer 30

Blood loss during delivery Diuresis and diaphoresis in the first 3 days Extra fluids are eliminated Potential for shock r/t blood loss Diverting of 500-750cc blood from placenta back into circulation Rapid reduction in uterine size returning blood flow systemically Continuation of hypercoagulable state

Question 31

Endocrine changes

Answer 31

Oxytocin from the pituitary gland coordinating uterine contractions. Breastfeeding increases oxytocin excretion Decreased estrogen, progesterone and placental enzyme insulinase with the passing of the placenta Can lead to depressive symptoms Prolactin level increases with breastfeeding

Question 32

Average postpartum blood loss with vaginal delivery and c-section

Answer 32

Average blood loss with a vaginal delivery: 500 cc or less | Average blood loss with a C-delivery is 1000cc or less

Question 33

when can postpartum hemorrhaging occur?

Answer 33

Postpartum hemorrhages are considered either early, within 24 hours of delivery, or late if after 24 hours but can occur up to 6 weeks after delivery. Most are early

Question 34

mothers and activity return

Answer 34

It is important that the mother very gradually resumes her daily activities over the course of several weeks so that she is not at risk for a postpartum hemorrhage

Question 35

Role adaptation

Answer 35

``` Accepting role as mother Changing relationship with partner Changing relationship with extended family “Bonding” to infant Body image changes ```

Question 36

role adaptation phases

Answer 36

Taking in Taking hold Letting go

Question 37

Taking in

Answer 37

→ first couple of days Passive dependent behavior as she relies on others for help & guidance. Repeats birth story.

Question 38

Taking hold

Answer 38

→ lasts from 2 days until 10 days to several weeks. Asserts her independence as the primary caretaker of her infant. She may verbalize fatigue, insecurity in skills, needs for nurturing and acceptance. Optimal time for teaching (but often discharged at this time) Prone to depression Decreased ability to fight off infection w lack of sleep

Question 39

Letting go

Answer 39

→ she assumes her position at home and adjusts to her tole Focus is on the forward movement of her family unit Reestablishes her relationship with her partner and may resume intimacy Still prone to fatigue and depression

Question 40

parts of maternal identity

Answer 40

commitment acquaintance/attachment moving toward achievement of maternal identity

Question 41

commitment

Answer 41

attachment to the unborn baby, and preparation for delivery and motherhood during pregnancy

Question 42

acquaintance/attachment

Answer 42

to the infant, learning to care for the infant, and physical restoration during the first 2 to 6 weeks following birth

Question 43

moving toward

Answer 43

a new normal

Question 44

achievement of a maternal identity

Answer 44

through redefining self to incorporate motherhood (around 4 motnhs). the mother feels self confident and competent in her mothering and expresses love for and pleasure interacting with her infant

Question 45

promoting infant bonding

Answer 45

``` Allow contact Allow her to undress the infant Encourage “en face” positioning Mother and baby’s face are in alignment Recognizes infant as unique individual Recognizes infant characteristics with different family members Touches, hold, and maintains proximity ```

Question 46

behaviors to watch for with infant bonding

Answer 46

Responds to cues from infant and provides care Smiles at and talks to infant Communicates pride in infant Assigns meaning to the infant’s behavior and views positively

Question 47

Potentially pathological signs to watch for with infant bonding

Answer 47

Apathy, turns away from infant, does not seek proximity Disgust in infant bodily functions, methodical care, ignores infant Views infant’s behavior as deliberately uncooperative or disruptive Expresses disappointment in the infant, does not talk about the infant’s unique features Handles the infant roughly Lack of preparation for the infant

Question 48

Partner attachment to the infant (7 behaviors)

Answer 48

Engrossment of the partner is characterized by seven behaviors: Visual awareness of the newborn- the father or partner perceives the newborn as attractive, pretty, or beautiful Tactile awareness of the newborn- the father or partner has a desire to touch or hold the newborn and considers this activity to be pleasurable Gut flora of the mother and father will colonize with the babies with skin to skin contact Perception of the newborn as perfect- the father or partner does not “see” any imperfections Strong attraction to the newborn- focuses all attention on the newborn when he is in the room Awareness of distinct features of the newborn- can distinguish his newborn from others in the nursery Extreme elation- feels a “high” after the birth of his child Increased sense of self-esteem- feels proud, bigger, more mature, and older

Question 49

complications

Answer 49

Hemorrhage Infection Thromboembolic disease Postpartum psychiatric disorders

Question 50

complication risk factors

Answer 50

Over distention of the uterus due to large baby, multiple gestation, multiparity Multiparity- multiple pregnancies (8-9) Rapid or prolonged labor Oxytocin induction of labor Precipitous induction of labor Precipitous delivery, C-section Prolonged or premature ROM (rupture of membranes) Amniotic sac fluid → broken, potential for bacteria to migrate up into the uterus Urinary catheterization Intruse bacteria into urinary tract

Question 51

Factors associated with development of Mastitis

Answer 51

milk stasis promotion of access/multiplication of bacteria breast/nipple trauma obstruction of ducts change in number of feedings/failure to empty breasts lowered maternal defenses

Question 52

milk stasis

Answer 52

Failure to change infant position for lobe emptying Failure to alternate breasts when feeding Poor suck Poor letdown Letdown starts about 2 weeks after breastfeeding Ducts of the breast start to contract toward the nipple Not enough contraction → no letdown

Question 53

promotion of access/multiplication of bacteria

Answer 53

Poor hand washing Improper breast hygiene Failure to air dry breasts after feeding Use of plastic lined breast pads that trap moisture

Question 54

breast/nipple trauma

Answer 54

Poor latch Incorrect positioning Aggressive pumping Failure to rotate position on the nipple

Question 55

obstruction of ducts

Answer 55

Restrictive clothing Constrictive bra Underwire bra

Question 56

Changes in the number of feedings/failure to empty breasts

Answer 56

Attempted weaning Missed feedings Prolonged sleeping, including sleeping through the night Feeding primarily from one side because of nipple soreness

Question 57

Lowered Maternal Defenses

Answer 57

Fatigue | Stress

Question 58

Complication signs and symptoms

Answer 58

Hemorrhage: Vaginal bleeding Persistent bleeding in the presence of a firmly contracted uterus Rise in the level of the fundus in the abdomen, uterine atony, “boggy” uterus Indicative of uterine atony Abnormal clots We should see a lemon-sized clot Unusual pelvic discomfort or backache Associated with hematoma formation in the tissues of the perineum Increased pulse, decreased BP, lightheadedness, syncope, SOB Hematoma formation or shiny bulging skin in the perineal area Decreased LOC Lowered Hgb and Hct

Question 59

S/S that should be assessed for postpartum complications

Answer 59

infection blood clots depression

Question 60

S/S of infection

Answer 60

Fever Purulent discharge from vagina or incision Erythema at incision site Increased WBCs Burning during urination Redness/pain in breast about 4th postpartum week (when mastitis begins)

Question 61

S/S of blood clots

Answer 61

Positive Homan’s sign- one leg not the other More pain when standing Skin color changes Pain Tenderness Swelling in lower extremities (calf/thigh)

Question 62

S/S of depression

Answer 62

Overwhelming sadness Low self esteem Lack of desire to care for child

Question 63

Factors associated with an increase in thromboembolic disease

Answer 63

``` C-section Hypercoagulated state in a less active person More potential for blood to pool Inactivity Obesity Cigarette smoking Previous thromboembolic disease Trauma to the extremity Varicose veins Diabetes Advanced maternal age Inherited thromboembolic disorders Multiparity Anemia ```

Question 64

Postpartum psych disorders

Answer 64

Most women (up to 80%) experience a transient period of mild depressive symptoms in the first 2 weeks after delivery This is postpartum blues- not depression About 15% of women will experience more severe symptoms that set in later A much smaller percentage will develop a postpartum psychosis. This requires a period of hospital evaluation, stabilization and treatment

Question 65

depression

Answer 65

Observe the new mother for objective signs of depression, listen for feelings of failure and self accusation Overwhelming feelings of sadness or inability to care for infant- provide list of support orgs in the community Women w postpartum depression usually need to be on medication for 6 months Also benefit from therapy A history of depression in the past puts the woman at increased risk for postpartum depression Postpartum depression is most severe in first time mothers (primparas) than in women who have had children before (multiparas)- observe for episodic tearfulness Note if mother feels overwhelmed, unable to cope, fatigued, anxious, irritable, oversensitive

Question 66

Complications influencing physical healing

Answer 66

Her general health and comfort level (prior and at delivery) Physical strain her labor created Perceptions of the birth experience Relationship with partner and mother Social support available Her ability to rest in the first few weeks Nutrition

Question 67

Postpartum Nursing Care Assessment

Answer 67

``` Assessments include: Physical assessments Interactions with and care of infant Support systems Pain level and coping strategies Educational needs ```

Question 68

B in bubble

Answer 68

breasts for filling, nipple status and engorgement (rare) Nipples prone to trauma with breastfeeding Engorgement is rarely seen in the hospital because milk does not start to come in until 3-5 days after she delivers

Question 69

U in bubble

Answer 69

fundus in relation to the umbilicus Where is the uterus in relation to the umbilicus? Fundus= top of uterus Palpate to assess for location Muscle fibers of the uterus must contract around the blood vessels that have supplied the baby → minimize potential for hemorrhage

Question 70

B in bu(b)ble

Answer 70

abdominal incisions, bowel sounds and distention, elimination voiding and bowel Assess risk for paralytic ileus

Question 71

B in bub(b)le

Answer 71

perineum including: Swelling, ecchymosis, hematomas Lacerations or episiotomies and the status of their repairs Hemorrhoids

Question 72

L in bubble

Answer 72

lochia flow

Question 73

E in bubble

Answer 73

edema and Homan’s sign Edema can be indicative of hypertensive disorders of pregnancy- some lethal Homan’s sign- bring mothers toes back toward face and assess for pain in calf

Question 74

How long are women prone to blood clots after she delivers?

Answer 74

24 weeks | more serious as closer to delivery

Question 75

When would you see changes in VS in relation to hemodynamic status?

Answer 75

30% of blood

Question 76

When would you see changes in VS in relation to hemodynamic status? (significant changes)

Answer 76

50% of blood

Question 77

When would you see VS changes in anemic women related to hemodynamic status?

Answer 77

smaller blood loss

Question 78

When would you see blood pressure elevations related to preeclampsia?

Answer 78

START IN POSTPARTUM