Postpartum Care Flashcards
What is postpartum ?
interval between birth and the return of the reproductive organs to their normal nonpregnant state
- aka the 4th trimester
What marks the beginning of the postpartum period ?
delivery of the placenta
- postpartum period takes about 6-8 weeks
In the immediate postpartum period, what is the nurse doing ?
- assessing mother and providing comfort measures
- assessing newborn
- promoting family-infant bonding
- providing education
What does BUBBLE HEN stand for ?
- breasts
- uterus
- bowel
- bladder
- lochia
- episiotomy (lacerations or incision)
- Homans’s sign (DVT)
- emotions
- nutrition
What types of hormonal changes happen after delivery ?
- Prolactin in increased and this stimulates milk production
- estrogen and progesterone is decreased
What is colostrum ?
first milk produced
- packed with IgA (passive immunity)
- high in protein, calories, and vitamins
- aka “liquid gold”
How do we ensure the mother keeps producing breastmilk ?
- put baby to breast q2-3hrs because large gap of time without stimulation causes body to stop producing milk
How can be stop milk production in the mother ?
- wear a tight-fitting bra
- when showering turn back to warm water to not stimulate production
When do the breasts obtain mature milk ?
72-96 hrs (3-4 days)
What assessments do we do for the breasts ?
- palpate tissue for fullness and tenderness
- ask if they feel breast being full
- inspect for signs of red, cracked, or blistered nipples
- if baby has poor latch it can hurt the nipple
What are some breast care we can implement ?
- clean with warm water and dry thoroughly (no soap because it can stay on nipple and baby can consume it)
- if leaking, use absorbent breast pads
- apply breast milk to nipple and areola after feeding and let air dry (will prevent blistering/cracks)
- lanolin or gel pads (can prevent blisters/cracks)
- cabbage leaves inside bra to help decrease pain & engorgement
What is engorgement ?
vascular congestions related to increased blood and lymph supply
- occurs day 3-5 postpartum
- breasts are swollen, hard and painful
- difficult for infant to latch and feed
What is primary engorgement ?
happens the first few days because of an increased blood supply to prepare for breastfeeding
- mom only really makes colostrum those first few days
What is secondary engorgement ?
caused by an increase of milk supply and baby isn’t drinking enough to empty them
What are some interventions for engorgement ?
- frequent breastfeeding (every 1-2 hrs or long enough to empty breasts)
- warm shower or compress to stimulate letdown
- alternate breasts with each feeding
- milk analgesic before feeding (ibuprofen)
- ice packs between feeding
- lactation specialist
What is mastitis ?
breast infection that occurs after milk is established
- S&S: red spot or hard lump, warm to touch and tender, may have discharge, fever from mild to severe, itchiness, enlarged/changed nipple sensation
- Tx with antibiotics and mild pain relievers
- continue to breastfeed (milk isn’t infected so its ok for baby to breastfeed)
What is involution ?
return of the uterus to a nonpregnancy state following birth
- processes rapidly
- Fundus (top) descends 1 to 2 cm every 24 hrs
- no longer palpable 2 weeks postpartum
- returns to a non-pregnant state by 6 weeks postpartum
What are some assessments we do on the uterus ?
- bimanual palpation of the fundus
- assess fundal height, firmness, and position
What are contractions and afterpains ?
cramping due to uterine contractions
- lasts 2-3 days
- breastfeeding can intensify afterpains and slow uterine bleeding
What are some interventions for contractions and afterpains ?
- heat
- ambulation
- mild analgesic (Naproxen, Ibuprofen)
- the more babies mom has delivered the more intense the afterpains are
Why is Oxytocin given after the delivery of the placenta ?
given as a bolus because we want the uterus to contract firmly so the blood vessels that were connected to the placenta will constrict to prevent hemorrhage
What is uterine subinvolution ?
failure of uterus to return to non-pregnant state
What are common causes of uterine subinvolution ?
- retained placental fragments
- pelvic infections
What are some assessment findings of uterine subinvolution ?
- may be febrile
- tender uterus
- boggy uterus (soft/spongy)
- prolonged or late postpartum bleeding
What is the tx for uterine subinvolution ?
- antibiotics
- uterine curettage (Dilation &Curettage which is where the cervix is dilated and we scrap uterine tissue)
- uterotonic medications to induce contractions
What is a adherent retained placenta ?
the placenta is still attached
- more common in premature births because the placenta is not ready to detach on its own
How do you detect placental fragments ?
with ultrasound
What is uterine atony ?
failure of the uterus to contract after delivery
- happens because the uterus gets tired or it gets distended
What are the causes of uterine atony ?
- polyhydramnios (too much amniotic fluid)
- macrosomia (big baby)
- multiple gestation or high parity (triplets/quadruplets)
- birth trauma
- magnesium sulfate
- rapid or prolonged labor
- chorioamnionitis (infection)
- use of Pitocin for induction or augmentation
- full bladder
- retained placenta
What is the priority nursing intervention for uterine atony ?
fundal massage
What is the leading cause of postpartum hemorrhage in the 1st hour ?
uterine atony
How do you perform a fundal massage ?
non-dominant hand is above the symphysis pubis to prevent any downward displacement, uterine prolapse or inversion
- the other hand is cupped to massage and gently compress the fundus toward the lower uterine segment
What are some medications we may use for postpartum hemorrhage ?
- Oxytocin (Pitocin) rapid IV infusion
- Methergine (methylergometrine) IM (want to avoid in pt’s with high BP
- Hemabate (carboprost tromethamine) IM (want to avoid in pt’s with asthma because it constricts the bronchioles)
- Cytotec (misoprostol) rectally
What are some devices we may used for postpartum hemorrhage ?
- Ballon Device (Bakri): goes inside the uterus and fills up the balloon to put pressure on the site where the placenta was to stop the bleeding
- Vacuum-induced (Jada): goes into uterus and instead of pressure it acts as a vacuum that stops the bleeding (is connected to suctioning)
What is hemorrhagic shock ?
hypovolemic shock secondary to hemorrhage
- OB emergency
What should you do if your pt goes into hemorrhagic shock ?
- stay calm
- continue fundal massage to keep uterus firm
- administer uterotonic medications as ordered by MD
- monitor VS, determine underlying cause, restore volume with IVF (LR, NS) and blood products
- protect and maintain airway
- inform family with simple explanations
What is postpartum infection ?
puerperal infection: any infection of genital tract within 28 days of delivery
- causes: streptococcal, staph aureus, E. Coli
What are some risks of postpartum infection ?
- immunosuppression
- anemia
- hemorrhage
- diabetes
- prolonged rupture of membranes (ROM)
- long labor
- intrauterine monitoring
- operative birth
- retained placenta
What are some prevention measures for postpartum infection ?
- handwashing
- nutrition
- perineal hygiene
- aseptic technique with childbirth
- antibiotics
What is endometritis ?
infection where the placenta was attached
- most common postpartum infection seen with C-sections, prolonged labor, or prolonged ROM
What are some S&S of endometritis ?
- chills
- fever
- tachycardia
- nausea
- fatigue
- anorexia
- tender uterus (may have guarding)
- foul smelling lochia (discharge)
- increased bleeding
- increased sed rate & anemia
- increased WBC
What is the tx for endometritis ?
- broad spectrum IV antibiotics
- hydration
- rest
- pain management
What happens to the bowels of someone in postpartum ?
- can take 2-3 days for a BM after delivery
- constipation is normal (encourage early ambulation, fiber intake, hydration, stool softeners)
- pain anticipated by pt if they had a repair
What are some assessments that can be done related to the bowels ?
- auscultate bowel sounds
- ask pt about last BM and flatus
- hemorrhoids are common during pregnancy, can be worse after delivery
What are some interventions for the bowels ?
- stool softeners
- TUCKS pads (witch-hazel round pads that can help with hemorrhoid pain)
What happens to the bladder postpartum ?
- birth induced trauma can occur to bladder (can be painful to void post repair)
- postpartum diuresis (losing excess fluid)
- excessive bleeding can occur because of displacement of the uterus if bladder is full (inability to void post anesthesia and increased risk of UTI)
What do you assess about the bladder ?
assess ability to void
- amount, color, and odor
What is lochia ?
uterine blood or discharge after delivery
What do you assess about the lochia ?
assess color, amount, and consistency
- may contain clots initially
- resembles heavy period first 2 hrs postpartum
What is rubra lochia?
consists of blood and trophoblastic debris
- bright red, fleshy odor, lasts 3-4 days postpartum
What is serosa lochia ?
old blood, serum, leukocytes and tissue debris
- pinkish brown color, starts at 3-4 days and lasts 22-27 days after delivery (can go away at 10 days)
What is alba lochia ?
consists of WBCs, decidua, epithelial cells, mucus, serum and bacteria
- yellowish white color, lasts from 4-8 weeks postpartum
What is an episiotomy/lacerations/incision ?
surgical incision made into perineum during delivery
- heals within 2-3 weeks
What kinds of lacerations are there ?
traumatic or spontaneous
- 1st to 4th degree
- locations: labia, perineal, vaginal, cervical, periurethral
- repaired vs. heal naturally
What do you assess for in episiotomy/lacerations/incisions ?
- visually inspect perineum for intact sutures (if repaired), swelling and redness
- side-lying position
- excessive postpartum bleeding may be due to unrepaired lacerations(s) or hematoma
What do you assess if your pt delivered via C-section ?
inspect incision for:
- intactness
- redness
- bleeding
- tenderness
What is a 1st degree perineal tear ?
skin is torn
What is a 2nd degree perineal tear ?
perineal muscles are torn all the way to the anal sphincter
What is a 3rd degree perineal tear ?
the tear includes the anal sphincter
What is a 4th degree perineal tear ?
the tear includes the rectum
What are some perineal tear interventions ?
- pt should lie on side as much as possible
- analgesics and/or topical anesthetics (dermaplast or epifoam)
- ice packs for first 12-24 hrs to decrease swelling
- sitz baths 3-4 times/day
- change pads regularly & with each stool/void
- teach perineal cleaning: hand hygiene, mild soap & warm water, clean front to back, use squeeze bottle, avoid wiping
What are some postpartum C-section care ?
- frequent assessments during recovery- VS, fundal checks, incision
- safety considerations/risk for falls due to anesthesia/analgesics
- incisional care and assessment
- fundal height and massage more of a challenge
- foley catheter/bladder
- pain management
- promote bonding
What is Homan’s sign ?
dorsiflexion of the pt’s foot
- if pain is felt behind the knee, then it’s considered a (+) Homan’s sign
- to detect DVT
- no longer routine
- inspect calf for edema, inflammation, heat, redness and tenderness
What is venous thromboembolism (VTE) ?
formation of blood clot inside blood vessel due to inflammation (thrombophlebitis)
- body wants to naturally form clots of prevent hemorrhage but that’s a problem postpartum
- superficial
- deep venous thrombosis
- pulmonary embolism
How do we prevent venous thromboembolism (VTE) ?
early ambulation
- due to venous statis & hypercoagulability
What are some risk factors for venous thromboembolism ?
- C section pt’s
- varicose veins
- age
- obesity
- smokers
- genetics
- immobility
What are some risk factors for DVT ?
- preeclampsia
- hypertensive disorders
- C-section
- any condition that causes pt to be on bedrest/decreased mobility
How is DVT diagnosed ?
ultrasound or venous study
- doppler flow studies
What are some interventions for DVT ?
- heparin or lovenox
- bed rest, elevate leg
- analgesics
- watch for PE
- SCDs and/or compression stockings
- avoid prolonged standing
How do we assess the pt’s emotional state ?
- edinburg postnatal depression scale (EPDS)
- assess bonding/engagement in care of newborn
What are the baby blue’s ?
is normal in the first 2 weeks postpartum
- emotional
- crying for no reason
- may also experience fatigue
- insomnia
- anxiety
- irritability
- fluctuating mood
- increased emotional reactivity
What is postpartum blues ?
50-85% mother in first 2 weeks postpartum
What is the postpartum depression ?
10-20% mothers in first year postpartum
- moderate to severe symptoms, prolonged course
What are some S&S of postpartum depression ?
- excessive guilt
- anxiety
- anhedonia (inability to experience joy)
- depressed mood
- insomnia/hypersomnia
- suicidal ideation
- fatigue
What is postpartum psychosis ?
0.01% mothers in first 3 months postpartum
- severe, considered psychiatric emergency
- often necessitates hospitalization
- pt can be a danger to themselves and their children
What are some S&S of postpartum psychosis ?
- mixed or rapid cycling
- agitation
- delusions
- hallucinations
- disorganized behavior
- cognitive impairment
- low insight
What are some nutrition considerations ?
- iron and iron-rich food is needed for blood loss
- protein for healing
- 300 to 500 extra calories if breastfeeding
- 1800 to 2000 calories per day for non-breastfeeding mothers
- 300 extra calories a day when pregnant
How is the cardiovascular system during pregnancy ?
- blood volume increase 40-45% during pregnancy
- blood loss during delivery and hormones affect CV system
- increased HR and decreased BP when hemorrhaging
What is usually the first sign of hemorrhaging ?
increased HR
What happens to the cervix during postpartum ?
- soft immediately after birth
- during the next 12-18 hrs the cervix shortens, becomes firm, and regains pre-pregnant form
- external os does not regain its pre-pregnancy appearance
- cervical os dilated to 10 cm during labor
What happens to ovulation and menstruation postpartum ?
- ovulation occurs as early as 27 days
- menstruation within 3 months after birth for non-breastfeeding moms
- breastfeeding mom have elevated serum prolactin levels which suppress ovulation
- can still ovulate and menstruate but this does not prevent pregnancy
For the musculoskeletal what is pelvic muscular support ?
supportive tissues of pelvic floor torn or stretched during childbirth
What happens to the abdomen post-partum ?
during first 2 weeks abdominal wall remains relaxed
- woman has a still-pregnant appearance
- return to prepregnancy state takes 6 weeks
What is diastasis recti abdominis ?
abdominal wall separates
What special consideration is there about the Rubella (MMR) vaccine ?
do not get pregnant 1 month after getting this vaccine
- can cause congenital birth defects
What special considerations are there about the RhoGAM vaccine ?
give again within 72 hours after birth to prevent Rh isoimmunization
- Rh sensitization due to mixture of fetal and maternal blood
- RhoGAM kills fetal RH positive blood cells before mom develops antibodies
What are the 4 T’s of postpartum hemorrhage ?
- tone (uterine atony)
- trauma (laceration, uterine inversion)
- tissue (retained placenta)
- thrombin (DVT)
