Postpartum Adaptations and Nursing care Flashcards
Assessment of the Postpartum Client
- Pre-pregnancy the uterus is about the size of a fist
- During pregnancy the uterus stretches to accommodate the size of the baby
Involution:
is the rapid reduction of the uterus to the nonpregnant size and condition
Routine Physical Assessment:
Skin/ v/s
- Head to Toe
- General response
- Skin (diaphoresis, edema)
- Vital Signs: must be consistent with pregnancy (ex: if pt was hypertensive before birth, the pt should still have increased BP)
- BP-consistent with BP during pregnancy
- Temperature 36.2-38C [98-100.4F]
Blood Loss:
- 200-500ml a blood loss is WNL for natural birth
- Up to 1000 mL (1L) is WNL fo C-section
Signs of hemorrhage:
- Orthostatic dizziness
- weakness
- fatigue
- SOB
- tachycardia
- hypotension
- pallor
- cold
- moist skin
- saturating a pad in 1 hr
Breast
Nipples
- Flat, inverted, cracked, sore; can make it difficult to be BF.
Skin at nipple site
- Condition: intact, Cracked, sore
Breast consistency
- Soft, firm, engorged
Lactation status
- Colostrum: is what comes before milk, it is a thick yellow and contains lots of nutrients and antibodies the baby needs.
— Last 1-3 days
- milk
Uterus
Fundus: the top of the uterus.
- Immediately after birth the fundus is halfway between the symphysis pubis & the umbilicus
- 12-24 hours after the delivery the fundus should be at the umbilicus
- The fundus should descend in one finger breath (1 cm) every day postpartum
Access Fundus for:
Consistency
- Firm
- Boggy:
— Boggy fundus: is a softer uterus that is not contracting,
we start with a fundal massage for one minute if it is still bogging, this is indicative of a postpartum hemorrhage.
- Stay with patient and call for assistance
- Or call HCP while following protocol
- Likely administer Pitocin to firm the uterus and stimulate contraction
Location
- Height in relationship to Umbilicus
- Midline or deviated
Bladder
- Assess for distention: can cause the fundus to shift; ensure patient is voiding
- Assess first few voids need to pee 3 times before DC
Amount, Color, Character - Check for catheterization orders
Bowel
Assess for
- Bowel sounds
- Flatus; can be painful if they are not passing gas- can lead to referred pain in shoulder
- Bowel movements
— Most women are also constipated after birth because of pain medication
— The extra progesterone slows down, bowel movement
— NPO at the time of admission
- Give stool softeners as necessary
- Encourage diet & fluids
- Teach about prevention of constipation
Lochia
discharge after birth
Lochia Assess:
Color:
- Rubra (dark red- lasts 1-3 days),
- Serosa (pinkish)- lasts 4-10 days
- Alba (white)- lasts until the placenta heals- (4-6 weeks)
Amount:
- Scant, <2.5 cm (1-inch) stain
- Light, 2.5- 10cm (1-4 inch) stain
- Moderate, 10-15 cm (4-6 inch) stain
- Heavy, saturated in 1 hr
- Lochia amount increases after getting up out of bed for the first time. Make sure mom knows this is normal.
- Extra activity or breast-feeding also increases the amount of lochia due to increased Pitocin
- Lochia should stop within 4-6 weeks (signifying the site of the placenta has healed)
- Foul odor
- Clots
Lochia: Scant
<2.5 cm
1 inch stain
Lochia: light
2.5 to 10 cm
1 to 4 inch
Lochia: moderate
10 to 25 cm
4 to 6 inch
Lochia: Heavy
Saturated in 1 hour
Lower Extremities
- Assess for Thrombophlebitis: inflammation of the vein related to DVT
- Homen’s Sign: indicates DVT, it is pain when the knee is bent
- if on Magnesium Sulfate (causes muscle weakness)- assess Deep Tendon Reflexes
- Assess for Edema
Episiotomy/C-Section Suture Site: Assess
Assess incision site: REEDA
- Redness
- Edema
- Ecchymosis
- Discharge, drainage
- Approximation
Assess perineum-hemorrhoids
Emotional Status
- En Face:
- Puerperal Phases:
- *Bonding
- Attachment
- En Face: mom and baby face to face
Puerperal Phases: postpartum phases-mom recognizing new role as a mom - Taking In Phase
- Taking Hold Phase
- Letting Go Phase
Affective Disorders
Post Partum Blues
Post Partum Depression
Post Partum Blues
- Transient- resolve within 2 weeks
- Emotional lability: happy one second & Sad the next
- Signs: Sad, crying, insomnia, poor appetite, anxiety
- Mother still able to care for self and infant
- Affects up to 80% of all mothers
Post Partum Depression
- Longer lasting. Onset within 4 weeks of birth and lasts at least 2 weeks.
- Change in appetite & sleep
- Loss of interest in all activities. Unable to care for self or infant
- Difficulty concentrating, thinking
- Thoughts of suicide
- *Unable to care for self or infant
- Affects 10%-15% of all mothers
PPD Risk Factors
- Previous PPD
- First pregnancy
- Hormonal fluctuations
- Immaturity or low self esteem
- Dysfunctional relationship
- Single, young maternal age (lack of support)
- Unwanted or unplanned pregnancy
PPD Treatment
- Psychotherapy
- Antidepressants (SSRI, Tricyclic)-most considered safe during breastfeeding
- But Takes up to 4 weeks to become effective and must be continued for 12 months after symptoms subside
- Brexanolone infusion (Gaba-A receptor): 60 hour infusion- very expensive
Discharge Teaching
- Breast Care
- *Breast Feeding
- Diet
- Lochia
- Postpartum complications
- Comfort measures
- Resumption of sexual activity: (when placental site heals 4-6 weeks)
- Contraception
- Newborn care
- Nutrition
- Exercise
- s/s of PP depression
