Postpartum Care Flashcards
Postpartum
Postpartum: delivery through 6 weeks
“4th trimester”
AKA “puerperium”, from the Greek “puerperos”, meaning “to bear young”
Puerperal = postpartal
Key task: involution
Involution
Uterus returns to its normal position, shape, size
Position: pelvic organ
Shape: upside-down pear
Size: fruit-basket pear
Uterus Decreases in Size
- Uterine contractions
- Autolysis
- Catabolic process
- Muscle fibers get smaller
- Protein from myometrial cells reabsorbed
Endometrial Changes
- Uterine contractions decrease placental site to ½ predelivery size
- Blood loss controlled
- Compression of blood vessels that supply decidual sinuses
- Compression of sinuses themselves
- Clot formation in vessels that supply **decidua - endometrium **
WBCs
Infiltrate placental site, blood vessels, and surrounding tissues
Necrosis begins
3 weeks total for decidual necrosis/regeneration
+
3 weeks for placental site necrosis/regeneration
Lochia (Postdelivery Flow)
After delivery, almost entirely blood
As sinuses compressed, clots form, less blood
Forms
1. Rubra (red)
2. Serosa (pink)
3. Alba (yellowish-white)
Lochia Rubra: 2-3 Days
Blood + mucus + decidual particles + cellular debris from placental site
Endometrial cavity sterile initially, then bacterial growth + WBCs contribute to lochia
Lochia Serosa: At 3-4 Days
L_ess oozing blood, more watery (serous)
Pinkish-tan color_
Involution of placental site continues: blood decreases, WBC + cellular debris
predominate
Lochia Alba: By Day 10
Yellowish-white to white in color
Gone by end of 3rd PP week or brownish mucoid discharge few days
Peripad Assessment (1 Hour)
Scant; Light; Moderate; Heavy saturated
PPH (Postpartum Hemorrhage)
Early PPH
Within first 24 hours
Uterine atony #1 ( uterus without tone, not contracting) , also genital tract lacerations and retained placenta
Late PPH
After first 24 hours
Retained placenta
Fundal Height
Fundus ( top portion of the uterus ) - at or below the level of umbilicus
Empty bladder - two-handed approach - palpate the abdoemn gently feeling for the top of the uterus while the other hand is placed on the lower segment of the uterus to stabilize it.
* By the 10th day PP, uterus is no longer palpable abdominally
if it is palpable - subinvolution due to retained placenta
Fundal Characteristics
Should be firm, in the midline
Reference position to the umbilicus
FF U/0 (at the level of umbilicus) , FF U/1 (1 cm below) , etc. !!!!!!
FF ( fundus firm) 1/U ( 1 cm above) , FF 2/U ( 2 cm above) , etc.
Boggy Uterus
Uterus not firm? Massage & reassess.
Support base of uterus
Massage fundus straight down towards patient’s spine
Note passage of clots, retained placenta, pieces of amniotic sac
Full Bladder
Too high? Over to right side? Probably full bladder. Have patient void & reassess.
Medications: Promote Uterine Tone
-
Pitocin (oxytocin)
10 units (1 ml) IM
Vastus lateralis or directly into myometrium if C/S patient
Up to 30 units (3 ml) into 1000 cc bag of an electrolyte solution
Titrate rate to keep uterus firm, bleeding minimal
2. Methergine (methylergonovine)
O.2 mg IM or IV
Note patient’s BP before administering
IV carries more risk of complications (HPN, CVA)
Bimanual Compression
Used for severe cases of uterine atony
Combined with use of oxytocic medications
1 hand in vagina; other on abdomen
Bakri Tamponade Balloon
Into uterus - fill with saline - leave - direct pressure on wound - stop bleeding
Afterpains
Primipara: uterus contracts & stays contracted
Multipara: intermittent uterine contractions
Worse with breastfeeding (oxytocin) !!! - lets milk down + uterus contractions
Problems maintaining contraction
- Uterus overdistended
- Clots or retained placenta
- Use of pitocin during labor
Cervix
Cx & lower uterine segment thin & collapsed; poor tone
Cx soft, edematous, many small lacerations
External os gradually closes & thickens
Vagina
- Damage to soft tissues & support structures
- Small tears in fascia & musculature - Vagina: smooth, swollen, poor tone
- Tone restored, but rarely like nullipara’s
- Rugae reappear after 3 weeks; many not as thick as before
- Estrogen deficiency by 3-4 weeks = atrophy of epithelial cells (vaginal tissue)
- Poor lubrication, vasocongestion, sexual response
- Estrogen normal level 6-10 weeks - no intercoarse until 6 weeks post
Introitus ( vaginal opening )
Red & swollen, especially if episiotomy or lacerations
Heals by 2 weeks PP if no infections or hematomas
Free of perineal pain
**Extensive lacerations or poor repair = relaxed perineal floor - urine and fecal incontinence **
Layers of Tissue in Perineum
Degrees
1st: perineal skin + subcutaneous layer
2nd: addition of perineal muscles
3rd: addition of rectal sphincter
4th: addition of rectal mucosa
Episiotomies cut through 2nd degree
Lacerations (tears) usually 1st & 2nd degree
Periurethral lacerations
Episiotomies
- Midline (median)
- Mediolateral
Right or left
Pericare (Perineal Care)
- Ice packs x 24 hours - reduce swelling ( 20 min on ; 20 min off)
- Sitz baths ( 2/ day , 10 min ) - warmth brings blood flow to the area - WBC ( healing) + RBC
- Peribottle
- Topical lidocaine ( allergic to novocaine)
Sprays
Foams
Creams - Tucks (witch hazel) pads
Special Considerations: 3rd & 4th Degree Lacerations
Nothing per rectum
Edema
Bruising
Emphasize dietary changes
Increase fluids
Increase intake of fruits/vegetables
Encourage ambulation
Stool softeners
Laxatives
* occur with midline episiotomie
REEDA Scale
Redness
Edema
Eccyhmosis
Discharge
Approximation
* Blue+black dime or smaller - ice for an hour; bigger - call doctor - hematoma - up to 1000 cc blood loss
Fallopian Tubes
Respond to low estrogen level
Transient, non-bacterial inflammation by PPD #4
Gone once estrogen levels are restored to normal
Hormonal Changes
Decreased estrogen & progesterone reactivates hypothalamic-pituitary-ovarian feedback
cycle
FSH & LH rise gradually
Lower level than normal menstrual cycle
Breastfeeding governs if normal ovarian function, ovulation, menstruation returns
Bottlefeeding or Breastfeeding < 28 Days
FSH & estrogen levels rise to follicular phase concentration by 3rd week PP
Menses can occur 6-8 weeks PP
Menses before 6 weeks usually anovulatory
Initial ovulation usually about 10 weeks PP
By 12 weeks PP, 70% have first menses
Breastfeeding
Associated with delayed ovulation
Menses return more gradually
12 weeks PP: 45% have menses
36 weeks PP: 55-75% have menses
First 1-2 cycles usually anovulatory
Unclear why delay in menses: possible influence of prolactin
Puerperal Morbidity: 1-8%
Morbid temperature:
38 degrees Celsius (100.4 F) or greater, after the first 24 hours PP, on any 2 consecutive
days out of the first 10 PP days
1. Endometritis
2. UTI
3. Thrombophlebitis
4. Mastitis
Endometritis
More common in C/S
Lower abdominal pain
Foul-smelling lochia
Treated with oral antibiotics for mild cases; IV for moderate/severe cases
Use of broad-spectrum antibiotics
Rapid response to medications typically
UTI
Same S/S of any UTI (urgency, frequency, dysuria)
Also flank pain if pyelonephritis (CVA tenderness)
Usually from bowel contaminants
Often were catheterized during labor
Diagnose with urine C/S (straight cath.)
Treat with antibiotics
Thrombophlebitis
Blood is hypercoagulable due to increased clotting factors
Venous stasis also a factor
Many patients have varicose veins
May have + Homan’s Sign
Red streaks on leg
Warmth, edema of leg
Treated with heat, elevation, NSAIDs, anticoagulants
Mastitis
Frequently unilateral
Tender, engorged, erythematous breast
Malaise (feel “flu-like”)
Usually due to S. aureus
Treatment: antibiotics, rest, fluids, Tylenol, empty affected breast q3h, ice, breast support
Can develop into breast abscess (surgical drainage)
