Postpartum. Lecture 8 Flashcards
Postpartum: the period between the birth of the newborn and the return of the reproductive organs to their normal non-pregnant state. This is Usually complete by 6-8 weeks post-birth for most people.
1.5 months
Postpartum Physiologic Adaptation
& Nursing Care
Reproductive System Adaptations:
- Uterus:
- After childbirth, the uterus undergoes involution, gradually returning to its non-pregnant size and position through uterine muscle contractions.
- Vagina:
- Vaginal and perineal tissues may become swollen and tender post-delivery, especially with tears or episiotomy, but typically heal with time.
Urinary System Adaptations:
- Bladder:
- Pregnancy and delivery pressure may temporarily weaken the bladder, leading to frequent urination or temporary urinary incontinence, with normal function eventually returning.
GI System Adaptations:
- Digestive System:
- Pregnancy-related digestive changes like slowed digestion and constipation tend to revert to pre-pregnancy levels.
- Appetite:
- Postpartum appetite may fluctuate, and some individuals may experience nausea or vomiting, similar to early pregnancy symptoms.
Cardiovascular & Respiratory System Adaptations:
- Cardiovascular:
- Blood volume decreases, heart rate gradually normalizes, and blood pressure typically stabilizes after childbirth.
- Respiratory:
- Pregnancy-induced respiratory changes, including increased oxygen demand, return to normal postpartum.
Musculoskeletal & Integumentary System Adaptations:
- Muscles and Joints:
- Muscles and joints, affected by pregnancy’s weight, experience relief as weight is lost, though abdominal muscles may take time to regain tone.
- Skin:
- Stretch marks may fade over time, and skin pigmentation changes (e.g., linea nigra) usually regress.
Endocrine System Adaptations:
- Hormones:
- Postpartum hormonal fluctuations persist, with increased prolactin levels to facilitate breastfeeding and a gradual return to pre-pregnancy estrogen and progesterone levels, leading to the resumption of the menstrual cycle.
Reproductive System Adaptation: Postpartum “OB” assessment
Head to Toe Assessment with a Focus on Specific Areas:
Vital Signs Assessment:
- Monitor vital signs, including blood pressure, heart rate, respiratory rate, and temperature.
Fundal/Uterine Assessment:
- Fundal Height: Measure uterine fundus height to assess position and involution. Ideally, it should gradually descend in the days following childbirth.
- Uterine Tone: Palpate the uterus to determine its firmness. A contracted uterus indicates good involution, while a soft or boggy uterus may suggest uterine atony and a risk of postpartum hemorrhage.
- Location of the Fundus: Assess if the fundus is midline or deviated, often measured in finger-breaths (approximately 1 cm). Deviation may indicate a full bladder, commonly displacing the uterus to the right side.
Lochia Assessment:
- Lochia Color: Observe the color progression from bright red (lochia rubra) to pink or brown (lochia serosa) to yellow or white (lochia alba) over several days.
- Lochia Amount: Estimate lochia as scant, moderate, or heavy. Note any sudden increase or passage of large clots, which may indicate an issue.
- Lochia Odor: Check for any foul odor, which could signal infection.
Vaginal/Labial/Perineal Assessment:
- Perineal Inspection: Examine the perineum and vaginal area for swelling, bruising, tears, or episiotomy incisions. Look for signs of infection or hematoma.
- Hemorrhoids: Assess for the presence of hemorrhoids or rectal issues.
- Vaginal Assessment: Observe for signs of vaginal bleeding, discharge, or infection.
Pain Assessment:
- Pain Location: Inquire about the location and intensity of any pain or discomfort, especially in the abdominal and pelvic regions.
- Pain Medication: Determine if the patient has received pain relief medications and evaluate their effectiveness.
- Pain Management: Discuss pain management strategies, including non-pharmacological methods such as relaxation techniques and positioning.
REPRODUCTIVE SYSTEM ADAPTATION:BUBBLE-E-E ASSESSMENT. It’s to know the points to cover during the assessment.
B - Breast:
- Assess breasts for engorgement, tenderness, or nipple issues.
- Evaluate breastfeeding status and offer guidance or support as required.
U - Uterus:
- Palpate the uterine fundus to check firmness, height, and position.
- Ensure appropriate uterine involution (returning to pre-pregnancy size).
B - Bladder:
- Assess voiding ability and inquire about discomfort or difficulty.
- Monitor signs of urinary retention postpartum.
B - Bowel:
- Inquire about bowel movements and assess for constipation or discomfort.
- Provide guidance on maintaining regular bowel habits postpartum.
L - Lochia:
- Examine vaginal discharge (lochia) for color, amount, and odor.
- Ensure the expected progression from rubra (red) to serosa (pink) to alba (white).
E - Episiotomy/Perineum:
- Inspect the perineum for swelling, bruising, tears, or episiotomy incisions.
- Assess for signs of infection or hematoma.
- Provide perineal care and educate on care techniques.
E - Emotions:
- Evaluate emotional well-being.
- Inquire about emotional state, including signs of postpartum depression, anxiety, or mood changes.
- Offer emotional support and referrals as needed.
Note: “E” traditionally stands for “Edema,” but the Homan’s sign for deep vein thrombosis assessment is no longer recommended as a routine part of postpartum assessment. DVT assessment should rely on clinical suspicion and risk factors, not routine maneuvers.
Reproductive System Adaptation: Fundal Assessment
- Involution: The natural process of the uterus returning to its normal, non-pregnant size and position after birth. It begins with the delivery of the placenta and involves smooth uterine muscle contractions.
- Subinvolution: When the uterus doesn’t return to its non-pregnant state as expected. This can occur due to retained placental fragments (causing confusion in the body), infections, or bleeding.
- Uterine Assessment: Healthcare providers assess the uterus by palpating its top part (fundus) through the abdomen. They evaluate its firmness, position relative to the umbilicus, and whether it’s in the midline, right, or left.
Comprehensive Postpartum
Nursing Assessment
Include bubble in this. Check the :
1) Head-to-toe assessment: Q shift and PRN
2) Vital signs (VS) and obstetric (OB) assessment till 2 hours postpartum (PP):
- Every 15 minutes for the first hour
- Every 30 minutes for the second hour
Vital signs (VS) and obstetric (OB) assessment: - Twice per shift in the first 24 hours
- Once per shift for more than 24 hours postpartum
Additional post C-section (c/s) assessments as needed because it’s a special case
PROCESS OF INVOLUTION
- Contraction of uterine muscle fibers (cells) leads to hemostasis.
- Blood comes from the placental adherence site due to placental detachment, exposing vasculature developed to support the placenta.
- Hemostasis is achieved by compressing intra-myometrial blood vessels during uterine contractions.
- Strong vessels surrounding these blood vessels cause contractions.
- After childbirth, the uterus usually involutes, clamps down, and constricts around these muscles if everything is normal.
- Catabolism results in the shrinking of enlarged myometrial cells.
- Uterine lining regenerates after the shedding of lochia.
- Uterus weighs 2.2 lbs (1,000 g) at the time of full-term birth and returns to 2 oz at 6 weeks postpartum.
- Fundus is not palpable by 10 days post-birth if everything is OK.
FACTORS PROMOTINGINVOLUTION
- Oxytocin (Pitocin):
- Endogenous oxytocin is a hormone crucial for promoting uterine contractions.
- Synthetic oxytocin, known as Pitocin, is often administered during labor to strengthen contractions and reduce postpartum bleeding.
- It can also be administered after childbirth to help the uterus contract and facilitate involution.
- Breastfeeding:
- Breastfeeding triggers the release of endogenous oxytocin.
- The oxytocin released during breastfeeding stimulates uterine contractions, aiding the uterus in returning to its normal size and position.
- Frequent breastfeeding in the early postpartum period is beneficial for involution.
- Urine Output:
- Maintaining adequate urine output is essential for postpartum recovery.
- A filled bladder can interfere with uterine contractions, so promoting regular urination helps ensure proper involution. If the bladder is full, it moves the uterus, delaying recovery and potentially causing hemorrhage in some cases.
- Fundal Massage:
- Fundal massage involves gently massaging the uterine fundus to stimulate contractions and encourage involution.
- Healthcare providers often perform fundal massage during the immediate postpartum period to prevent postpartum hemorrhage and promote uterine tone.
- Ambulation:
- Encouraging postpartum individuals to ambulate (walk) is beneficial for involution.
- Walking helps improve uterine tone and circulation, which can aid in the involution process.
- Medical Interventions (Hemabate, Misoprostol, Methergine):
- These medications are used for preventing hemorrhage.
- Hemabate, Misoprostol, and Methergine are uterotonic medications that stimulate uterine contractions and promote involution.
- Their use is determined by a healthcare provider based on the individual’s condition and medical history.
FACTORS INHIBITING INVOLUTION
- Retained Placental Fragments:
- Assess the placenta to ensure its integrity, typically done by a doctor or midwife.
- Fragments of the amniotic sac or placenta left in the uterus can hinder proper uterine contractions and lead to delayed involution. This is because the brain doesn’t get the signal that the pregnancy is over.
- Extended IV Pitocin:
- While Pitocin is used to promote uterine contractions and involution, excessive and prolonged administration can oversaturate oxytocin receptors, causing the uterus to relax instead of contract.
- Bedrest:
- Prolonged bedrest can result in reduced uterine tone and muscle activity, slowing down the involution process.
- Bottle-Feeding:
- Breastfeeding releases endogenous oxytocin, aiding in uterine contractions and involution, which bottle-feeding does not provide.
- Tocolytics:
- Tocolytics are medications used to inhibit uterine contractions, sometimes in situations like preterm labor.
- Excessive or inappropriate use of tocolytics before birth can hinder uterine involution after childbirth.
- Precipitous Labor:
- Extremely fast labor and delivery can result in inadequate uterine contractions, potentially leading to delayed involution, especially in multiparous individuals.
- Uterine Infection:
- Infections of the uterine lining (endometritis) or surrounding tissues can cause inflammation and hinder uterine involution due to impaired muscle contraction.
- Full Bladder:
- A full bladder can exert pressure on the uterus, preventing effective contractions. Regular bladder emptying is crucial in the postpartum period.
- Coagulopathy:
- Coagulopathy refers to blood clotting disorders, such as thrombocytopenia or DIC.
- Postpartum individuals with coagulopathies are at an increased risk of bleeding and delayed uterine involution due to clotting abnormalities.
Why Fundal Massage postpartum ?
Stimulating Uterine Contractions through Fundal Massage:
- Fundal massage promotes uterine contractions, serving two crucial purposes:
- Preventing Postpartum Hemorrhage:
- Uterine contractions close off blood vessels at the placental site, preventing excessive bleeding.
- This reduces the risk of postpartum hemorrhage, a potentially life-threatening complication.
- Expelling Blood and Tissue:
- Uterine contractions assist in expelling any remaining blood clots or tissue fragments from the uterus.
- This clears the uterine cavity of debris, supporting a healthy postpartum recovery.
Monitoring Uterine Involution:
- Fundal massage enables healthcare providers to assess the uterus’s condition.
- By palpating the uterine fundus (top portion of the uterus), they evaluate its consistency, firmness, height, and position.
- A well-contracted, firm uterus is a positive sign of uterine involution.
Preventing Uterine Atony:
- Uterine atony, ineffective uterine contractions after childbirth, can lead to excessive bleeding and postpartum hemorrhage.
- Fundal massage helps prevent uterine atony by encouraging strong contractions and maintaining uterine firmness.
Ensuring Proper Fundal Position:
- Fundal massage can also correct uterine deviation or displacement, often caused by a full bladder.
- Ideally, a midline fundus position promotes effective uterine contractions.
Lochia Assessment
Lochia Stages Postpartum
Lochia Rubra (Days 1-3days Postpartum):
- Duration: Typically lasts for the first 1-3 days after childbirth.
- Composition: Mainly composed of blood from the placental site, decidual tissue, debris, and mucus.
- Color: Bright red, resembling menstrual blood.
Lochia Serosa (Days 3-10 Postpartum):
- Duration: Typically starts around the third or fourth day postpartum and may continue for up to 3-10 days.
- Composition: Contains a mixture of blood, serum, leukocytes (white blood cells), and tissue debris.
- Color: Pinkish brown, less red, and more watery compared to lochia rubra.
Lochia Alba (Weeks 2-6 Postpartum):
- Duration: The final stage, lasting several weeks, often up to 3-6 weeks postpartum.
- Composition: Mainly consists of leukocytes (white blood cells), decidual cells, mucus, serum, and possibly some residual tissue debris.
- Color: Lighter in color, described as light brown or white, signaling the end of the healing process.
Lochia Assessment 1
Amount:
- In the immediate postpartum period, it’s typical to anticipate approximately 6-8 pad changes per day, although this can vary among individuals.
- Monitoring the amount of lochia is crucial to ensure that postpartum bleeding remains within a normal range.
- Excessive bleeding, defined as saturating more than one pad per hour, may indicate postpartum hemorrhage and requires immediate medical attention.
- As the postpartum individual recovers, the amount of lochia gradually decreases over time.
Odor:
- Lochia generally has a mild, earthy odor, similar to menstrual blood, which is considered normal due to the presence of blood and tissue debris.
- However, a foul or offensive odor may indicate an infection, necessitating prompt reporting to a healthcare provider for evaluation.
Clots:
- Small blood clots (up to the size of a grape) can be normal in the immediate postpartum period as the uterus contracts and expels blood and tissue.
- Nevertheless, large or frequent clots, especially in association with heavy bleeding, may signify a problem requiring reporting to a healthcare provider.
- It’s important to inquire about the duration a pad has been in place if there is concern about the amount of blood, as 300 ml in 8 hours is not the same as 300 ml in 20 minutes. Additionally, asking about the last time the individual urinated is essential, as a prolonged period without urination can hinder uterine involution due to bladder pressure.
Lochia Assessment continues
- Scant:
- Minimal vaginal discharge, typically less than 2.5 cm (approximately 1 inch) on a sanitary pad.
- Considered normal as the postpartum body begins to recover.
- Light:
- Slightly increased vaginal discharge compared to scant, generally less than 10 cm (about 4 inches) on a sanitary pad.
- Normal in the early postpartum period.
- Moderate:
- Significant vaginal discharge, typically greater than 10 cm on a sanitary pad.
- Within the expected range for the first week or so after childbirth.
- Heavy:
- Substantial and continuous vaginal discharge, saturating a pad within 2 hours.
- May indicate postpartum hemorrhage or other serious issues requiring immediate medical attention.
- Using a pad is preferable to monitoring blood in the toilet.
Duration of Cervical Opening:
After childbirth, the cervix typically remains open for a period of approximately 4 to 6 days.
Circle on left is the way it loos like before the birth. The one on the right is a multiparous cervix.
Cervical os never goes back to original position after the first delivery.
Vagina and Perineum
Vagina and Perineum Postpartum
Bruising and Edema of the Perineum:
- Bruising and swelling of the perineum can vary from patient to patient and should be assessed based on individual symptoms and severity.
Lacerations/Episiotomy (Incision):
- Assess and care for lacerations or episiotomies as needed to promote healing.
Hemorrhoids:
- Address hemorrhoids as necessary for symptom relief and comfort.
Decreased Estrogen:
- After childbirth, estrogen levels decrease, leading to changes in the vaginal mucosa. This can result in the thinning of the vaginal tissue and smoothing of the rugae (grooves) inside the vaginal wall.
- Recommend waiting for at least one month before resuming sexual activity to allow for healing.
- Suggest using lubrication postpartum due to increased dryness, particularly during the first 3-4 weeks, especially if the individual is breastfeeding.
Full assessment includes turning patient on her side .slide
This is a very swollen rectum and perineum.
- Severe swelling in the rectum and perineum, likely causing significant pain and requiring extensive repair suturing.
- Potential difficulty with voiding for the patient.
- Advisable to position the patient on her side for a better assessment, though such cases are relatively uncommon.
- Lying in the supine position for an extended period can exert pressure on the sacrum and coccyx, leading to discomfort or pain.
- Turning the patient onto her side helps alleviate this pressure and enhances comfort.
- Preventing pressure sores (bedsores) by redistributing pressure and improving circulation to vulnerable body areas.
- Enabling healthcare providers to assess skin integrity on the back, sacral area, and buttocks for redness, irritation, or pressure ulcers.
- Early detection of skin issues is vital for prevention and treatment.
- Assisting respiratory function, particularly crucial after a cesarean section or in patients at risk of postoperative complications.
- Promoting improved lung expansion and ventilation by turning the patient onto her side.
- Encouraging mobility and preventing complications associated with prolonged immobility, such as blood clots and muscle stiffness.
- Offering a change in position for increased comfort, which is essential for postpartum recovery and adequate rest.
Perineal Hematoma: usually we can not see the source of the bleeding because it’s internal. But overtime we can see some swelling.
Causes:
- Childbirth: Perineal hematomas often occur in women who have given birth vaginally due to the stretching and tearing of blood vessels in the perineal area during the baby’s passage.
- Episiotomy: Performing an episiotomy (surgical vaginal opening enlargement) during childbirth can increase hematoma risk.
- Other Trauma: Perineal hematomas can result from non-childbirth-related trauma, such as accidents or falls.
Symptoms:
- Swelling and Tenderness: The primary symptom of a perineal hematoma is swelling and tenderness in the perineal area.
- Discoloration: Hematomas can cause bluish or purplish discoloration in the affected skin.
- Pain: Pain levels vary based on the hematoma’s size and location.
- Pressure Sensation: Some individuals report a feeling of pressure or fullness in the perineal area.
Diagnosis:
- Perineal hematomas are typically diagnosed through a physical examination by a healthcare provider.
- Ultrasound may be used to assess the hematoma’s extent and location.
Treatment:
- Small hematomas may resolve spontaneously, but larger or painful ones may need medical intervention.
- Treatment options include hematoma drainage, pain management, and monitoring for infection signs.
- Severe hematomas or those causing complications may require surgical intervention.
Complications:
- Left untreated or if infected, perineal hematomas can lead to serious complications.
- Complications may include infection, abscess formation, or tissue necrosis.
- Prompt diagnosis and appropriate treatment are crucial to minimize complication risks.
Hemorrhoids
Postpartum Rectal Symptoms and Interventions
Symptoms:
- Itching and discomfort in the rectal area.
- Bright red bleeding after having a bowel movement.
Interventions:
- Stool softeners to ease bowel movements.
- Witch hazel pads (Tucks) for soothing relief.
- Topical ointment for localized discomfort.
- Increased fiber in the diet to promote regular and softer stools.
- Laxatives if necessary to alleviate constipation.
Nursing Care: Perineal Trauma
- Ice packs: 1st 24 hours for swelling
- Peri-bottle with every voiding if they have burning evertime they void to reduce pain and burning by diluting the urine.
Sitz Bath (after 24 hours). 10 min a couple of times a day to clean it and avoid inflammation as well as an improvement in circulation to heal faster. Use it at home after second degree lasceration.
Pain Control its gonna be oil and analgesics.
Urinary Tract: Postpartum Changes
Urinary Tract: Postpartum Changes
A. Decreased GFR & Renal Plasma Flow: (now we have less volume of blood, that’s why)
- After giving birth, the tone (or tension) and size of the structures in the urinary tract gradually return to their pre-pregnancy state, typically taking about 6-8 weeks for this process to complete.
Increased Output:
- Within the first 12 hours to one week after childbirth, you may experience diuresis, which is an increased production of urine. this is because we are trying to get rid of the excess fluid
Risk for Urinary Retention:
- Urinary retention, or the inability to empty the bladder properly, can be a concern postpartum. Several factors can contribute to this, such as swelling in the pelvic area, the use of anesthesia (especially opioids), a decreased urge to urinate due to post-birth discomfort, and pain, which can be exacerbated, for example, by perineal burns or tears.
Risk of Infection:
- It is crucial to discontinue the use of a Foley catheter as soon as it is medically safe to do so in order to minimize the risk of infection. Foley catheters, which are often used during labor or immediately after childbirth, can introduce bacteria into the urinary tract if left in place for an extended period, potentially leading to infections. Therefore, prompt removal is recommended to maintain urinary tract health.
Nursing Care:Urinary Tract Postpartum
Nursing Care: Postpartum Urinary Tract Care
A. Assisting the Patient with Voiding After Delivery
- Assess for fundal displacement.
- Encourage the patient to void every 2 hours.
- Provide pain relief and address edema or trauma:
- Apply ice.
- Administer analgesia.
- Sitz bath.
- Use topical spray for pain relief (Derma-Prost), applied before urination.
- Use benzocaine for pain relief.
- Add peppermint to the toilet water.
Difficulty in Voiding
- Possible reasons for difficulty voiding may include:
- Decreased sensation of a full bladder.
- Pain.
- Edema or trauma.
- Use peppermint essential oil in the toilet water if needed.
Documentation of Urine Output
- Document urine output per provider’s orders.
Bladder Scanner/Straight Catheterization as Needed (PRN)
- Utilize a bladder scanner or perform straight catheterization as necessary, based on clinical indications and provider orders.
GI Tract
Postpartum GI Tract Care
Bowel Tone Improvement
- Bowel tone will improve as progesterone levels decline.
- It might take up to 5 days for the body to return to normal bowel function.
Delayed Spontaneous Bowel Movement (Up to 5 Days PP)
- Delayed spontaneous bowel movements can occur for up to 5 days postpartum.
Labor/Birth Effects on GI Tract
- Pre-labor diarrhea (due to prostaglandin receptors).
- Lack of food can lead to delayed bowel movements (no food, no bowel movements).
- Dehydration can cause constipation.
- Anticipatory pain due to lacerations/tissue trauma.
C-Section Effects on GI Tract
- Intra-op narcotics.
- Disruption of intestines during surgery (surgery itself can affect the intestines).
- Delayed ambulation.
- NPO (not eating for an extended period). C-section patients can’t wait for 5 days.
Nursing Care for the GI Tract:
- Encourage hydration and ambulation.
- Promote a diet high in fiber.
- Administer stool softeners/laxatives/anti-gas medications as needed.
- Encourage normal food intake.
- Adhere to around-the-clock (ATC) non-narcotic pain management regimen post C-section.
- Provide comfort measures.
Nursing Care: GI Changes/Nutrition
Iron Supplementation
- Administer iron as needed (PRN).
Foods High in Iron
- Encourage consumption of foods rich in iron.
Iron Supplements
- Consider iron supplements, which can even be administered via infusion (less likely to cause constipation).
Patient Education
- Provide education about the constipating effect of iron supplements.
Cardiovascular System: Postpartum Changes
Cardiovascular Changes Postpartum
Heart
- The heart returns to its pre-pregnant position.
Cardiac Output
- Cardiac output gradually declines over a period of 3 months.
- Heart rate slows with reduced volume, but there is an increase in stroke volume.
Blood Pressure
- Blood pressure decreases during the first 2 days postpartum. (blood loss)
- It increases to normal levels by 6 weeks postpartum.
Blood Volume
- Blood volume drops rapidly postpartum and returns to the pre-pregnant state within 2-6 weeks.
Plasma Volume
- Plasma volume decreases through diuresis.
- Hemoglobin (H) and hematocrit (Hct) levels increase because now we have less plasma so they are not as diluted.
Cardiovascular System: Postpartum Changes
Cardiovascular System: Postpartum Changes
Increased Coagulability of Pregnancy
- Returns to pre-pregnancy state by 6 weeks postpartum.
- Enhanced coagulability is a natural adaptation to prepare for delivery and blood loss during childbirth.
Clotting Factors
- Clotting factors remain elevated for at least 2-3 weeks postpartum. To heal the uterus bleeding. Good but it can increase DVT wow !!
Monitoring for DVT/Thromboembolism
- Monitor for deep vein thrombosis (DVT) and thromboembolism due to increased coagulability.
- Educate patients about signs of DVT, such as calf pain and shortness of breath.
Hematocrit & Hemoglobin
- Experience an initial dip within the first 24 hours postpartum, followed by a rise. This is coz she lost blood during delivery
White Blood Cells (WBCs)
- WBC count increases during intrapartum to protect the baby.
- Return to normal levels at 4-6 days postpartum.
Respiratory System:Postpartum Changes
Respiratory System: Postpartum Changes
- Respiratory Rate (RR): Typically ranges from 16-24 breaths per minute.
- Diaphragm Returns to Normal Position: The diaphragm gradually returns to its pre-pregnant position postpartum.
- Relief from Shortness of Breath (SOB): Many women experience relief from shortness of breath as the diaphragm returns to its normal position.
- Tidal Volume and Functional Residual Capacity: Both tidal volume (the amount of air inhaled and exhaled during normal breathing) and functional residual capacity (the volume of air left in the lungs after a normal breath) return to their pre-pregnant state within 1-3 weeks postpartum.
