Postpartum Nursing L6 Flashcards
The fourth trimester of pregnancy:
The postpartum period – the time interval between birth and the return of the reproductive organs to their nonpregnant state
Puerperium:
The postpartum period
Length of normal puerperium:
About 6 weeks
Things that return to their nonpregnant state during peuperium:
1) Breasts
2) Uterus
3) Bowels
4) Bladder
5) Lochia
6) Episiotomy or laceration
7) Emotional state
8) Homans sign?
Normal VS values in postpartum:
- BP: <140/90 (check for orthostatic hypotension)
- Temp: 36.2-38
- HR: 50-90bpm
- RR: 16-20
- SpO2: >95%
- Pain: manageable
Acceptable QBL measurements:
- Vaginal: 300-500mL
- C/S: 500-1000mL
What happens to cardiac output after delivery?
CO stabilizes after delivery, drops 30% in the next 2 weeks, then reaches normal levels
Blood will return to prepregnancy state after postpartum by:
1) Eliminating uteroplacental circulation
2) Loss of placental endocrine function which removes stimulus for vasodilation
3) Getting rid of extravascular water
Temperature after delivery:
Can increase to 38C/100.4F due to dehydration
HR after delivery:
Is usually increased in the first hour after delivery – returns to pre-pregnant state by 8-10 weeks
RR after delivery
Usually decreases to pre-preg state by 8-10 weeks
Hgb/Hct after delivery
in the first 72 hours half of the RBCs gained during pregnancy are lost. Hemodilution occurs leading to decreased H&H and platelets by day 7
WBCs after delivery
- WBCs may be increased to 25-30k/mm3
- Normalizes in 1 week
Hypercoagulable state of PP pts can lead to:
Thromboembolism
Nursing assessments/interventions immediately following delivery:
Check BP, HR, RR, pain, lochia assessment, and perform fundal massage as follows:
1) Q 15 mins for 1 hr
2) Q 30 mins for 1 hour
3) Q 1 hr until stable
4) Q shift (ro more frequently if health history or current condition dictates
Things that are involved with C/S recovery:
same care as with vaginal delivery +:
1) Cardiac telemetry monitoring
2) Continuous pulse ox
3) Surgical site assessment
4) Urinary catheter
5) Return of sensation
6) Return of sensation/movement lost from spinal or epidural anesthesia
7) Gum in PACU
8) Incentive spirometer
9) Gradual build up to food (ice chips>sips>clear liquids>light solids(crackers)
Issues that can arise after C/S:
1) CV – hemorrhage, shock, DVT, DIC
2) Resp – pulmonary embolism, pneumothorax
3) GI - paralytic ileus
4) GU – renal failure, hematuria, UTI, oliguria
5) Reproductive – endometritis, emboli
6) Skin – wound infection, dehiscence
PP hemorrhage medications: Please Help Me To Clot
1) Pitocin (oxytocin)
2) Hemabate (carboprost)
3) Methergine (methylergonovine)
4) Tranexamic acid (TXA)
5) Cytotex (misoprostol)
Pitocin (oxytocin) for PP hemmorrhage:
- Route: IV or IM
- Usual dosage: 10-40 U in 500-1000mL
- Contraindications: none
Hemabate (carboprost) for PP hemorrhage:
- Route: IM
- Usual dosage: 250 mcg
- Contraindications: asthma
Methergine (methylergonovine) for PP hemorrhage:
- Route: IM
- Usual dosage: 0.2 mg
- Contraindications: HTN
Tranexamic acid (TXA) for PP hemorrhage:
- Route: IV
- Usual dosage: 1g/100mL given over 10 minutes
- Contraindications: none
Cytotec (misoprostol) for PP hemorrhage:
- Route: PR, buccal, SL
- Usual dosage: 400-1000mcg
- Contraindications: PR contraindicated in 3rd and 4th degree lacerations
READ P from book about Early PPH!!!
READ P from book about Early PPH!!!
Difference between early and late PPH
- Early postpartum hemorrhage – within 24 hours after delivery
- Late postpartum hemorrhage – 24hrs to 6 weeks postpartum
Breast assessment:
Inspect and palpate for:
* Redness
* Tenderness
* Areas of warmth
* Blisters
* Cracks
Expected findings of a breast assessment:
- Soft
- Non-tender
- Colostrum or milk easily expressed
- No areas of erythema
- Nipples intact
Breast care:
- Keep breasts open to air after feeding to prevent fungal infections
- Express some milk/colostrum after feeding to prevent damage
- Wash breasts with mild soap and water
- Use lanolin nipple cream prn for discomfort
Who should not use lanolin?
People allergic to wool
Lactational amenorrhea
Some do not ovulate or have menstrual cycles while breast feeding (DO NOT use as method of contraception)
What can strong tasting foods do to breastmilk?
Can change the taste of breastmilk (broccoli, onions, ect)
Remedies for feelings of breast engorgement:
- Warm compress/shower before feeding
- Ibprofen
What is helpful to do after breast feeding?
Applying cold compress or cabbage leaves
when does colostrum transition to milk?
in about 72-96 hours
lactogenesis 2
when colostrum transitions to mature milk
breast engorgement typically lasts…
24-48 hours if not breast feeding
when does engorgement occur in pts who are not breastfeeding?
on the third or fourth postpartum day
what can be used to relieve engorgement discomfort if they are not breastfeeding?
- breast binder or well fitting sports bra
- ice packs
- fresh cabbage leaves
- mild analgesics
- avoid nipple stimulation
how long does lactation last if expression never begins?
a few days to a week
expected findings of fundus palpation
1) fundus at the level of the umbilicus or below
2) firm
3) non-tender or slightly tender with deep palpation
4) @ the midline
typical fundus location @ 12 hours:
U to U+1
how quickly does the fundus typically descend
descends at 1-2 cm / 24 hours
the uterus is not palpable by which day PP?
by the 9th day
uterine subinvolution
failure of uterus to return to non-pregnant state
afterbirth pain in multips
afterbirth pain in multips is often increased
placental site regeneration time:
complete @ 6 weeks
changes in lochia:
1-3 days: rubra (bright red)
3-10 days: serosa (pink)
10days-2 weeks alba (white) - persists until 6-8 weeks
describe the cervix after birth:
cervix is bruised, soft, and wollen
* closed within 2 weeks
recovery of the vagina after birth
returns to pre-pregnancy state by 6-8 weeks
PP assessment of bowels:
- interview pt about recent BMs and passing gas
- auscultate bowel sounds
- palpate for distension
expected findings of bowel assessment postpartum
- normoactive bowel sounds x4 quads
- stools normal consistency
- passing gas
- non-distended abdomen
a spontaneous BM may not occur for 2-3 days after birth. why?
- slowed peristalsis related to decreased muscle tone in the intestines during labor and immediate postpartum period
- pre-labor diarrhea
- lack of food
- dehydration
third and fourth degree lacerations that involve the anal sphincter are associated with…
increased risk for anal incontinence
gum chewing in the PACU
reduced risk for postoperative ileus related to c/s surgery when pts chew gum in recovery; stimulates the GI tract
PP bladder assessment:
- measure output until >500mL/void or if on strict I&Os
- inspect urine
- palpate for distended bladder
- ask pt about urinary symptoms
expected findings for PP bladder assessment:
- pt can fully void
- clear, straw colored urine
- non-malodorous
- non-palpable
- no S/Sx UTI
common urine output/day for the first 2-3 days
3000mL/day is common for the first 2-3 days
length of renal system recovery postpartum
normal function returns within 6 weeks PP
excessive vaginal bleeding can occur if bladder is distended. why?
uterine atony (it moves the uterus which causes it to bleed)
if a pt is having difficulty urinating, what can you try?
peppermint oil and running water to try to stimulate urination
PP lochia assessment
- observe lochia
- measure significant bleeding for ongoing QBL assessment
PP lochia assessment expected findings
- scant or moderate lochia rubra
- no clots or few small clots
- discharge non-malodorous
- no bright red bleeding or trickle of blood
non-lochial bleeding
- if the bloody discharge spurts from the vagina, and the uterus is fully contracted, there may be cervical or vaginal tears in addiction to normal lochia
- if the amount of bleeding continues to be excessive and bright red, a tear can be the source
lochia when the uterus is massaged
a gush of lochia can appear as the uterus is massaged. if it is dark in color, it has pooled in the relaxed vagina, and the amount soon lessens to a trickle of bright red lochia
PP episiotomy/laceration assessment:
inspect episiotomy/laceration and the perineal area
expected findings for PP episiotomy/laceration assessment:
- intact repair, wound edges approximated
- minimal swelling after 24 hours
- no evidence of hematoma formation
- no malodorous discharge or other evidence of infection
- pain = minimal-moderate
nursing interventions for episiotomy/lacerations:
- ice to the perineam x 24 hours
- tucks pads (witch hazxel) pads are soothing
- teach pt how to use sitz bath
- peribottle used during voiding to reduce pain
- lidocaine spray to perineum for pain
- opioid meds for severe pain
S/Sx of hemorrhoids
- itching
- discomfort
- bright red bleeding with defecation
REEDA
assessment for perineal lacerations/episiotomies
R-edness
E-dema
E-ecchymosis
D-rainage
A-pproximation
recovery time for perineal lacerations/episiotomies
starts to heal: 2-3 weeks
completely healed: 4-6 months
recovery time for pelvic musculature
6 months - kegal exercise helps
what kind of birth is thromboembolisms more common?
c/s
PP DVT assessment:
inspect legs for S/Sx of DVT
PP DVT assessment expected findings:
- no calf pain upon dorsiflexion
- no areas of erythema or tenderness in calves
- minimal edema
- Normal DTRs
- lower extremity symmetry
PP emotional assessment
interview pt about:
* their emotional status
* feelings about birth experience
* risk-factors for PPD/PP psychosis
involve support people
PP emotional assessment expected findings:
- excited
- happy
- interested and involved in infant care
- sharing their birth story
- may be overwhelmed, tearful at times, exhausted
S/Sx of PP blues
- depression
- mood swings
- letdown
- fatigue
- anger
resolution of PP blues
usually resolves in 10-14 days
S/Sx of PP depression
- depression
- feeling of failure
- overwhelming guilt
- loneliness
more serious than PP blues
maternal adjustments
1) taking in - first 24 hours are focused on self and basic needs
2) taking hold - 10 days to several months are focused on care of baby and competent parenting
3) letting go - focus is on the family unit
what is the AAP recommendation for breastfeeding?
- exclusive breastfeeding for 6 months
- continue breastfeeding for at least a year
breastfeeding contraindications
- HIV+, active TB, HSV on breast
- parental T-cell lymphotropic virus 1 or 2
- newborn galactosemia
characteristics of colostrum
- produced for the first 2-3 days after birth
- lots of antibodies and protein
transitional milk
transition from colostrum to mature milk (3-5 days)
* increased supply
* may have engorgement
mature milk
at about 10 days
stages of lactogenesis
lactogenesis 1 - complete by gestational age 16-18 weeks
lactogenesis 2 - begins at birth
lactogenesis 3 - mature milk
signs of successful breastfeeding
- 6-8 wet diapers/day
- stools transition from meconium to mustard colored, seedy looking stools
- 3 stools/day by day 5
maternal intake related to breastfeeding:
- add 200-500 cal/day
- drink 2-3L/day
- continue prenatal vitamins
infant feeding cues:
- rooting
- sticking tounge out
- lip smacking
- sucking on hands, fingers, blanket
- opening mouth
- crying (late sign)
common problems associated with formula:
1) positioning - formula needs to cover nipple to reduce gas
2) warming - never microwave bottles
3) propping - never leave infant unattended while feeding, can lead to dental caries
postpartum immunizations:
1) rubella (MMR) for rubella non-immune
2) Tdap
3) Rhogam to Rh- birth parents (if baby is Rh+)
4) seasonal flue and covid
standard discharge timing after birth
48hrs after vaginal birth
96 hrs after c/s
early discharge after birth
12-24hrs after vaginal birth
24hrs after c/s
discharge criteria:
- VSS
- voiding
- Hbg>10
- no unusual bleeding
- instructions on self-care
- pain managed
- ambulating
- follow up scheduled
- normal physical assessment
- at least 2 successful feedings
- at least 1 void/1 defecation
- no/low jaundice
- circulation ok
- newborn blood/hearing screening/pulse OX completed
