Postpartum Flashcards
Early Postpartum
What is normal temperature?
What is abnormal temperature?
Differentials for abnormal temp?
Normal: 98.6-100.4, stabilizes during the first 24 hours postpartum
Abnormal: > 100.4
DDX for abnormal: infection, pulmonary embolism
Early Postpartum
What is normal pulse?
What is abnormal?
Differentials for abnormal pulse?
Normal: 65-80
Abnormal: >80
DDx: infection, increased blood loss, pulmonary embolism
Early Postpartum
What is normal BP?
What is abnormal BP?
Differentials for abnormal BP?
Normal: same as pre-pregnant, although transient increase in BP as much as 5% of baseline in 4 days after delivery
Abnormal: >140/>90: DDX postpartum hypertensive disorder, PEC
<90/<60: DDX blood loss, med reaction
Early Postpartum
Normal Neurologic assessment
Abnormal Neurologic assessment
Normal: A&O x3
Abnormal: disoriented, excessive sedation
Early Postpartum
Normal Lung assessment
Abnormal Lung assessment
Normal: No SOB, able to breathe without difficulties, clear to auscultation
Abnormal: SOB, adventitious breath sounds on
Early Postpartum
Normal Cardio assessment
Abnormal Cardio assessment
Normal: No CP, RRR
Abnormal: chest pain, palpitations, tachycardia
Early Postpartum
Normal Breast assessment
Abnormal Breast assessment
Normal: Nipples may be sore from nursing, but NOT painful; colostrum and breast fullness x3-5 days
Abnormal: Painful,cracked, bruised, blistered, bleeding nipples; no breast filling by day 5
Early Postpartum
Normal GI/Abdomen assessment
Abnormal GI/Abdomen assessment
Normal:
- eating and drinking without difficulty
- Return of bowel movement day 2-3 PP
- Presence of bowel sounds
- Decreased muscle tone
- Diastasis recti is expected
- Firm fundus and midline; level of fundus appropriate according to process of involution
- surgical scar is well approximated, without s/s of infection
Abnormal:
- nausea and vomiting, abdominal pain, constipation or diarrhea
- distended abdomen, unable to palpate uterus
- Fundal height not midline and level is increasing not according to PP day
- surgical scar is not well approximated, showing signs of infection and dehiscense
Early Postpartum
Normal Urinary assessment
Abnormal Urinary assessment
Normal:
- voiding spontaneously and without difficulty,
- diuresis,
- mild external burning, retention, incontinence, lack of sensation or urge to void is common in first 2 days
Abnormal:
- dysuria, persistent retention or incontinence, distended bladder, CVA tenderness
Early Postpartum
Normal Perineum assessment
Abnormal Perineum assessment
Normal:
- mmild erythema, bruising, edema;
-laceration/episiotomy repair is well approximated and without drainage,
-lochia decreasing in amount each day
Abnormal:
-worsening perineal tenderness, erythema, edema,bruising
- Presence of hematoma
- laceration/episiotomy repair is not well approximates, showing signs of separation
- malodorous lochia; excessive amounts with clots, soaking pads
Early Postpartum
Normal Anus assessment
Abnormal Anus assessment
Normal: hemorrhoids may be present, pink in appearance
Abnormal: hemorrhoids deep blue or purple
Early Postpartum
Normal LE assessment
Abnormal LE assessment
Normal: muscle soreness from positioning in labor, bilateral/symmetric edema
Abnormal: unilateral leg pain, unilateral calf tenderness, one leg more edematous than the other
What is uterine involution?
Process of the uterus returning to the pre-pregnant state - results from reduction in cell size (not number)
What is the normal process of uterine involution?
- Immediately after delivery: uterus contracts to about the size of a grapefruit, located halfway between umbilicus and symphysis pubis
- By 12 hours post-delivery: uterus is at the level of the umbilicus; fundus should be midline of the abdomen, if displaced to the side, may indicate a full bladder
- The fundus then descends about 1 cm per day
- By 2 weeks: uterus no longer palpated abdominally
- By 6 weeks: uterus returns to slightly larger than pre-pregnant state
What is Lochia:
Vaginal discharge in the post-partum period. Consists of the breakdown of myometiral placenta bed, eschar and decidual cells.
What are the 3 stages of lochia discharge?
Rubra, Serosa, Alba
Lochia Rubra:
Lasts: 3-7 days
Color: Red or red-brown
Description: Fleshy odor, contains superficial layer of decidua that has sloughed off the uterus, debris (cellular remains from vernix, lanugo, mec, necrotic placenta remains)
Lochia Serosa
Lasts: from day 14-21
Color: Pinkish-brown color
Description: Serous to serosanguinous secretion; contains blood, cervical mucus, erythrocytes, leukocytes, decidual tissues
Lochia Alba
Lasts: Until cessation of flow in about 4-6 weeks postpartum
Color: Yellowish to white discharge
Description: Flow increases with additional activity initially but decreases progressively
Normal Transition of the Cervix postpartum?
- Immediately after vaginal birth the cervix appears edematous dilated 3-4 cmand bruised, may have lacerations
- Day 2-3 PP: Continues to be dilated 2-3 cm
- By day 7: 1 cm
- By 4 weeks: No longer dilated
What does Multiparous Cervix look like at completion of involution?
External os does not return to its pre-pregnant appearance, remains somewhat wider with transverse opening, resembling a fish mouth
Normal Transition of the vagina Postpartum?
Immediately PP: edematous, relaxed, sometimes bruised with decreased tone
By 3-4 weeks PP: rugae return; edema, vascularity, and bruising decrease
By 6-10 weeks postpartum, vaginal epithelium
** Decreased Lubrication can lead to pain with sex, especially with breastfeeding***
Normal Transition of the Perineum Postpartum:
Immediately after birth: edematous with decreased tone, laceration and episiotomy repair should be well approximated
7 days PP: skin should appear healed with only linear scarring by 6 weeks
Normal Transition of Breast postpartum:
- colostrum is produced upon birth of baby, may even have colostrum production in 3rd trimester
- engorgement occurs approximately 72 hours after birth
- milk ejection reflex develops within the first 1-2 weeks
Normal transition of the hematologic system postpartum:
Immediately postpartum in the fist hours post birth: Cardiac output increases 60-80%
Over first 48 hours: diuresis occurs, plasma volume decreases and cardiac output normalizes by 2 weeks
Normal changes of Renal system PP:
Diuresis occurs within first 5 days as result of extravascular fluid shifts
Bladder can be hypotonic and edematous immediately after the birth: resolves in 24 hours
Prolonged labor, trauma to vulva, urethra or bladder, use of anesthesia during c/s can cause urinary retention
Normal Weight loss/caloric intake pp:
Caloric intake at least 1800 calories per day +500 cal if breastfeeding (more if twin breastfeeding)
No more than 4.5 lb/month of weight loss
Normal abdominal changes PP:
-decreased peristalsis in first 24 hours pp
- AST/ALT return to pre-preg levels by week 2
- diastasis recti found in 75-80% of pp women
-striae common
Endocrine changes in breastfeeding women:
- Lactation is stimulated and prolactin and oxytocin are secreted
- By negative feedback, ovulation and menstruation are inhibited by increased prolactin, resulting in estrogen suppression
- If exclusively breastfeeding, there is a 1-3% change of ovulation within the first 6 months PP
When will Menses return after weaning breastfeeding?
- generally ovulation 14-30 days after weaning, first menses 14 days later!
What is efficacy of LAM?
1-3% chance of ovulation in first 6 months PP if exclusively breastfeeding
Endocrine changes in non-breastfeeding women
Prolactin levels fall after initial engorgement
Hormonal shifts to stimulate ovulation begin 3-4 weeks pp
First menses: 6-8 weeks pp, 70% by 12 weeks
When to expect return to menses if NOT breastfeeding (never started)?
Avg: 6-8 weeks pp, 70% by 12 weeks
When to give Rhogam?
Anti-Rho(D) immune globulin (Rhogam) should be given within 72 hours of birth if mom is Rh neg and baby is Rh +
Vaccines to give immediately PP if not already received/immune?
Tdap, MMR, varicella, Flu, HPV, COVID
Common PP Discomfort: Involutional PAIN
Comfort measures?
- likely to increase with each subsequent birth and with nursing
NONPHARM: - maintain empty bladder and bowels
- relaxation and breathing techniques
- changing positions, sitting up, walking,
- applying heat,
- using abdominal support binder, lying flat on the abdomen
PHARM:
- ibuprofen
- acetaminophen
-Avoid opioids (some women are ultrametabolizers of codeine, which causes rapid conversion to morphine, which puts babies at risk of respiratory depression)
Common PP Discomfort: Diuresis
Comfort measures?
stay well hydrated to prevent dehydration
Maybe sleep with a towel under you/change of clothes nearby so you can quickly change out of wet clothes
Common PP Discomfort: Breast Engorgement
Comfort measures?
- Initiate breastfeeding early and often
- assess that infant is positioned correctly and properly latched
- at times, infants can’t latch to severely engorged breasts –> instruct patient to express small amount of milk manually before each feeding to soften the areola and allow the infant to latch properly
- can use pump to assist with softening the breasts before feeding by releasing enough milk for infant be able to latch
- avoid excessive pumping, as this increases breastmilk production and worsens engorgement
- supportive Bra
- warm compress or warm shower before feeding
IF bottle feeding:
- tight bra
- ice pack
-analgesics
- reassurance about time limitation
- cold cabbage leaves in bra for comfort
Common PP discomfort: Perineal Pain
Comfort measures?
- evaluate by REEDA (redness, edema, ecchymosis, discharge, approximation)
Topical meds/treatment:
- witch hazel pads
- dibucaine, benzocaine
- ice packs for first 24 hours
- sitz baths after 24 hours
- topical anesthetics
Common PP Discomfort: Constipation
Risk factors?
Comfort Measures?
Risk factors: lack of ambulation in labor and pp period (esp after c/s); decreased intestinal peristalsis due to anesthesia, narcotic use for pain
Comfort:
- increase fluids, fiber
- stool softener
-encourage ambulation
- laxatives if needed
Common PP Discomfort: Hemorrhoids
Prevention?
Comfort?
Prevention: bowl regimen of scheduled use of stool softeners to avoid constipation; avoid straining with bowel movement
Comfort: ice packs, topical anesthetics, referral if thrombosed
Postpartum blues
-affects 80% of women
- begins within 3-5 days of birth, concurrent with profound hormonal shifts
- Very labile emotions (giddiness, sadness, crying)
- generally time-limited over 1-2 weeks
- supportive, sensitive care is usually all that is needed
Postpartum Depression: Definition
Depression occurring anytime within 4 weeks after childbirth and up to 12 months
Risk factors for Postpartum Depression:
- hx of depression/anxiety, esp if untreated in pregnancy
- genetic
- social factors: IPV, prior abuse, lack of social support, negative life events
