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
Average postpartum blood loss with vaginal delivery and c-section
Average blood loss with a vaginal delivery: 500 cc or less
Average blood loss with a C-delivery is 1000cc or less
when can postpartum hemorrhaging occur?
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
mothers and activity return
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
Role adaptation
Accepting role as mother Changing relationship with partner Changing relationship with extended family “Bonding” to infant Body image changes
role adaptation phases
Taking in
Taking hold
Letting go
Taking in
→ first couple of days
Passive dependent behavior as she relies on others for help & guidance.
Repeats birth story.
Taking hold
→ 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
Letting go
→ 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
parts of maternal identity
commitment
acquaintance/attachment
moving toward
achievement of maternal identity
commitment
attachment to the unborn baby, and preparation for delivery and motherhood during pregnancy
acquaintance/attachment
to the infant, learning to care for the infant, and physical restoration during the first 2 to 6 weeks following birth
moving toward
a new normal
achievement of a maternal identity
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
promoting infant bonding
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
behaviors to watch for with infant bonding
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
Potentially pathological signs to watch for with infant bonding
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
Partner attachment to the infant (7 behaviors)
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
complications
Hemorrhage
Infection
Thromboembolic disease
Postpartum psychiatric disorders
complication risk factors
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
Factors associated with development of Mastitis
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
milk stasis
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
promotion of access/multiplication of bacteria
Poor hand washing
Improper breast hygiene
Failure to air dry breasts after feeding
Use of plastic lined breast pads that trap moisture
breast/nipple trauma
Poor latch
Incorrect positioning
Aggressive pumping
Failure to rotate position on the nipple
obstruction of ducts
Restrictive clothing
Constrictive bra
Underwire bra
Changes in the number of feedings/failure to empty breasts
Attempted weaning
Missed feedings
Prolonged sleeping, including sleeping through the night
Feeding primarily from one side because of nipple soreness
Lowered Maternal Defenses
Fatigue
Stress
Complication signs and symptoms
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
S/S that should be assessed for postpartum complications
infection
blood clots
depression
S/S of infection
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)
S/S of blood clots
Positive Homan’s sign- one leg not the other
More pain when standing
Skin color changes
Pain
Tenderness
Swelling in lower extremities (calf/thigh)
S/S of depression
Overwhelming sadness
Low self esteem
Lack of desire to care for child
Factors associated with an increase in thromboembolic disease
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
Postpartum psych disorders
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
depression
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
Complications influencing physical healing
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
Postpartum Nursing Care Assessment
Assessments include: Physical assessments Interactions with and care of infant Support systems Pain level and coping strategies Educational needs
B in bubble
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
U in bubble
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
B in bu(b)ble
abdominal incisions, bowel sounds and distention, elimination voiding and bowel
Assess risk for paralytic ileus
B in bub(b)le
perineum including:
Swelling, ecchymosis, hematomas
Lacerations or episiotomies and the status of their repairs
Hemorrhoids
L in bubble
lochia flow
E in bubble
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
How long are women prone to blood clots after she delivers?
24 weeks
more serious as closer to delivery
When would you see changes in VS in relation to hemodynamic status?
30% of blood
When would you see changes in VS in relation to hemodynamic status? (significant changes)
50% of blood
When would you see VS changes in anemic women related to hemodynamic status?
smaller blood loss
When would you see blood pressure elevations related to preeclampsia?
START IN POSTPARTUM
