Postpartum Flashcards
When does a low grade temperature change happen?
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
What does a temperature above 100.4 indicate?
an infection
Endometritis
- an infection developed in the uterus during labor
2. endometritis is a secondary infection of the uterus
What increases the risk of developing an infection in the uterus/endometritis?
If the water has been broken for > 24 hours
If the woman had a c-section
S/S r/t blood loss (or infection)
Elevations in the pulse and temperature rates can be related to blood loss or infection
SOB and syncope are indicators of SIGNIFICANT blood loss
What lab results do you look at to assess blood loss?
HCT and HGB
Review of rubella status and administrating the vax if _____ or _____
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
rh status and administration of rhogam
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
Postpartum
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
Immediate postpartum changes
- uterine involution
- cervical involution
- lochia flow
- decrease in vaginal distention
- breast changes
- urinary changes
- GI changes
- CV changes
- endocrine changes
Uterine involution
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
what is the number 1 cause of maternal death in the world?
POSTPARTUM HEMORRHAGE
Fundus location (after expulsion of placenta and after delivery)
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.
Why does the fundus height decrease each day?
Due to coagulation and relaxation
Why is it concerning if the uterus is above the umbillicus?
uterus is not well contracted and blood flow may increase
increase the risk of postpartum hemorrhage
What affects contraction of the uterus?
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
What happens when the bladder is distended
the fundus will be above the umbillicus and displaced to the right
Vaginal tone
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
Vaginal flow
Vaginal flow after delivery is usually representative of the shedding of the uterine lining and the oozing from the site of placental implantation
Excessive bleeding can come from…
Uterine atony (lack of contraction)
Unrepaired cervical, vaginal, or perineal lacerations
Retained placental fragments- uterus cannot contract effectively
Vaginal or vulvar hematomas
Coagulpoathies
Lochia Assessment
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)
Measuring lochia
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
Breast Changes
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
Ways to prevent nipple trauma
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
Breast engorgement prevention
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
Urinary changes
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
When is it necessary for a woman to void by?
8 hours
~ at least 150 cc
** if she is unable to void, she should be straight catheterized
Bowel Changes
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
Diastasis recti abdominis
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
CV changes
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
Endocrine changes
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
