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OB Nursing > Postpartum Physiological Adaptations > Flashcards

Postpartum Physiological Adaptations Flashcards

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1
Q

What is the average length of time for return to non-pregnant physiology?

A

6 weeks

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2
Q

What are the most significant risks during postpartum period?

A

Hemorrhage, infection, shock

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3
Q

Why are uterine contractions important after delivery?

A

Minimize bleeding

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4
Q

Define afterpains

A

Uncomfortable uterine cramping after delivery

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5
Q

What happens to estrogen after delivery?

A

It drops

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6
Q

Effects of decreased estrogen in PP

A

Breast engorgement (increased PRL), diaphoresis, diuresis, less vaginal lubrication

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7
Q

What happens to progesterone after delivery?

A

It drops

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8
Q

Effects of decreased progesterone PP?

A

Increased body muscle tone

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9
Q

What happens to blood glucose after delivery & why?

A

It drops due to decreases in placental enzyme insulinase

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10
Q

What happens to hCG after delivery?

A

It disappears quickly but can be detected up to 4 weeks PP

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11
Q

When does ovulation return in breastfeeding persons & why?

A

About 6 months PP due to suppression by PRL

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12
Q

What maintains PRL levels in breastfeeding persons?

A

Breastfeeding frequency, length of feeds, supplement use, infant suck

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13
Q

When does ovulation resume in non-breastfeeding persons?

A

7-9 weeks w/ menses resuming by 12 weeks

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14
Q

What are important components of PP assessment? (5)

A

VS, uterine firmness, uterine location relative to umbilicus, uterine position relative to midline, amount of vaginal bleeding

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15
Q

VS monitoring PP

A

BP, HR q15mins for first 2 hrs

Temp q4hrs for first 8 hrs, then at least q8hrs

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16
Q

BUBBLE: focused PP assessment

A

Breasts
Uterus - fundal height, uterine placement, consistency
Bowels & GI function
Bladder function
Lochia - color, odor, consistency, amount (COCA)
Episiotomy - edema, ecchymosis, approximation

*Also VS, pain, education

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17
Q

PP labs

A

Urinalysis, CBC (Hgb, HCT, WBC, platelet), Rubella titer, Rh status (if unknown)

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18
Q

Uterine involution

A

Rapid reduction in uterus size & return to pre-pregnant state

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19
Q

What enhances uterine involution?

A

Uncomplicated birth, complete expulsion of placenta/membranes, breastfeeding, early ambulation

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20
Q

How does breastfeeding enhance uterine involution?

A

Stimulates exogenous oxytocin release

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21
Q

Uterine subinvolution

A

Involution does not happen properly

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22
Q

Risk of improper uterine involution

A

PP hemorrhage

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23
Q

Uterine exfoliation

A

Healing of placenta site, important part of involution

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24
Q

What causes uterine involution?

A

Contractions

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25
Q

How do you assess uterus PP?

A

Cup uterus above symphysis pubis and palpate fundus

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26
Q

PP uterine assessments

A

Fundal height
Uterus location/position
Uterine consistency

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27
Q

How much does the fundal height change per day?

A

About 1 cm per day (one fingerbreadth)

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28
Q

Where should the fundus be 1 hour after delivery?

A

Umbilicus

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29
Q

When should the uterus no longer be palpable PP?

A

About 2 weeks

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30
Q

What should you do if the fundus is boggy?

A

Gently massage it in a circular motion

*If it doesn’t become firm, continue massaging and notify provider

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31
Q

How do you document PP fundal height?

A

Reference point = umbilicus (at umbilicus = UU)

Above umbilicus = number before U (e.g. 2 cm above = 2U)

Below umbilicus = number after U (e.g. 2 cm below = U2)

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32
Q

Where is the fundus and what does it feel like immediately after delivery?

A

1-2U and like a grapefruit

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33
Q

What can enhance involution/after pain?

A

Multiparas due to repetitive stretch of myometrial fibers
Overdistended uterus - multifetal, LGA, polyhydramnios, retained clots
Breastfeeding due to higher oxytocin

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34
Q

When does involution/after pain typically begin to subside?

A

By 3rd day = mild discomfort

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35
Q

Nursing interventions for involution/afterpain

A

Analgesics - ibuprofen, narcotics if necessary; facilitates milk ejection/letdown

Position changes –> prone w/ blanket under abdomen/pelvis

Heat

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36
Q

Lochia

A

Uterine debris ejected after birth

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37
Q

Typical lochia changes

A 
Birth - bright red
1-3 days - rubra (dark red)
4-10 days - serosa (pink, brown-tinged)
11-21 days (up to 6 weeks) - alba (white, cream, light yellow)
6+ weeks - clear
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38
Q

What causes fundal bogginess?

A

Uterine atony

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39
Q

What can cause uterine atony?

A

Blood clots, retained placenta

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40
Q

Why is it important for the birthing person to void after birth?

A

Bladder distention can displace uterus and stimulate atony

41
Q

Assessment of PP lochia

A

Scant - 1 inch stain

Small - <4 inch stain

Moderate - 4-6 inch stain

Heavy - >6 inch stain or saturated in 2 hrs

Saturated - saturated peripad in <1 hr

42
Q

Manifestations of abnormal lochia

A

Spurting of bright red blood from vagina

Numerous large clots w/ excess blood loss

Foul odor (infection)

Persistent heavy lochia rubra in early PP period beyond day 3 (retained placenta)

Continued serosa or alba beyond normal timeframe (endometritis)

43
Q

Cervical changes PP

A

Internal os closes, soft, external os may remain slightly open (1 cm) & slit-like

Potential edema, bruising, small lacs

44
Q

Vaginal changes PP

A

Rugae reappear by 3-4 weeks

Edema resolves by 6-10 weeks

Mucosa thickens w/ return of estrogen production

Muscle tone never fully restored

Dryness, atrophy, dyspareunia more likely in breastfeeding persons

45
Q

Nursing interventions for perineal tenderness, lac, episiotomy

A

Keep stools soft
Comfort measures - cold for edema/pain, hot packs, sitz bath
Non-opioids, NSAIDs, opioids (PCA)
Topical anesthetics (benzocaine spray, witch hazel)
Squeeze bottle w/ warm water or antiseptic solution to clean area

46
Q

Why can birthing persons tolerate substantial blood loss during birth?

A

Hypervolemia during pregnancy

47
Q

CV changes PP

A

Initial increase in CO then return to normal pre-labor values in 1 hr, then decrease to pre-pregnancy level by 6-12 weeks

Plasma volume normalizes via diuresis, diaphoresis

Blood values - leukocytosis during labor & immediately PP; normalizes by 6 days PP

Increased plasma fibrinogen increases clot risk for 4-6 weeks PP

48
Q

BP changes PP

A

Typically minimal, transient increase

If low, possible hemorrhage

If high, possible PP HTN

Orthostatic hypotension possible for 48 hrs PP

49
Q

Puerperal bradycardia

A

HR as low as 40 bpm, common

Assess tachycardia

50
Q

Fever PP

A

Normal to elevate to 100.4F for 24 hours

If >24-48 hrs, possible infection

51
Q

GI changes PP

A

Increased hunger, thirst

Constipation due to progesterone - spontaneous BM may not occur for 2-3 days, may anticipate discomfort

Normal BMs by 8-14 days

Flatulence may cause abdominal discomfort

Hemorrhoids may be present

52
Q

Urinary Tract changes PP

A

Diminished urge to void

Rapid bladder filling (diuresis) - risk for retention, distention, UTI

Stress incontinence - usually improves by 3 months PP; kegels help

*Straight caths preferred if needed

53
Q

Nursing assessments of urinary tract PP

A

Ability to void
Bladder elimination pattern
Bladder distention –> can displace fundus/uterus
Frequent voiding <150 mL –> retention w/ overflow

54
Q

MSK changes PP

A

Decreased relaxin –> joints/ligaments normalize

Increased muscle tone as progesterone decreases

Diastasis recti resolves w/in 6 weeks –> recommend gentle exercises to strengthen

55
Q

Neurologic changes PP

A

Bilateral, frontal headaches common first week due to changes in fluid/electrolyte balances; relief w/ Tylenol/ibuprofen; if not, assess for preeclampsia

Spinal headache –> after spinal anesthesia, relief when supine, may need blood patch

Monitor for preeclampsia

56
Q

When can ovulation resume for breastfeeding persons?

A

8 weeks to 18 months, average 6 months

57
Q

Weight loss PP

A

10-12 lb at birth

9 lb over first 2 weeks

Adipose tissue lost slower; 6-12 months to reach pre-pregnancy weight

58
Q

Typical hospital stays PP

A

Vaginal –> 1-2 days; more frequent assessments closer to delivery

C/S –> 2-4 days (3 nights), post-op pts

59
Q

Important labs to review from prenatal record in PP period

A

GBS status, HepBsAg status, syphilis screen

60
Q

Immune system review PP

A

Rubella titer - if negative/low ==> subq rubella or MMR vaccine

Rh - Rhogam at 28 weeks & 72 hrs PP

Varicella - if not immune, vaccine before discharge & 2nd dose 4-8 weeks

Tdap - before discharge or ASAP in PP period if not previously received

61
Q

PP Assessment Schedule (varies)

A

q15m for 1 hour, then

q30m for 1 hour, then

q1h for 2 hours, then

q4h for 24 hours, then

q8h until discharge

62
Q

Breasts PP

A

Colostrum secretion at 12 weeks and 2-3 days PP

Milk secretion 3-5 days PP

Changes - tenderness, engorgement, color, nipples (everted, flat, inverted), trauma, mastitis

63
Q

What should DTRs be PP?

A

1-2+ (mostly normal)

64
Q

Important orders needed in EHR before discharge

A

Breast pump, contraception, narcotics, home visits

65
Q

Four traditional positions for breastfeeding

A

Football, Cradle, Modified Cradle, Side-lying

66
Q

Comfort measures PP

A

Ice packs - reduce edema via vasoconstriction; 12-24 hrs after birth

Sitz baths - cool for first 12 hrs, warm after 24 hrs

Pericare - warm squeeze bottle, pat
dry

Aromatherapy - anxiety, nausea, pain

Acetaminophen, ibuprofen, narcotics

Topicals - witch hazel

67
Q

Breastfeeding education

A

Wash hands prior

Wear well-fitting bra w/o underwire

Allow on demand nursing (8-12 times in 24 hrs)

Offer second breast before completion; start w/ different breast each time

Drink adequate fluids, proper nutrition/caloric intake

68
Q

Relief of breast engorgement

A

Warm shower, warm compress before feeding to promote letdown & milk flow

Empty each breast completely each feeding, pumping if necessary

Cool compresses after feedings (seaweed leaves)

69
Q

Nipple care during breastfeeding

A

Breast creams - Lanolin

Breast shells for irritation, cracking

Flat/inverted nipples –> breast shell between feedings

Sore nipples –> apply small amount of milk to nipples, air dry

70
Q

Education for persons not planning to breastfeed

A

Lactation suppression –> continuous use of well-fitting, supportive bra for 72 hrs PP

Avoid breast stimulation, warm water on breasts for prolonged periods until lactation ceases

Engorgement –> cold compresses, 15m on, 45m off; cold cabbage leaves in bra

Mild analgesics/NSAIDs for pain/discomfort

71
Q

Exercises for PP birthing person

A

Pelvic tilt

Kegels

No abdominal exercises for C/S persons for 4-6 weeks

72
Q

Caloric needs of lactating persons

A

Extra 450-500 kcal/day

73
Q

Caloric needs of non-lactating persons

A

1800-2200 kcal/day

74
Q

How long should birthing persons take prenatal vitamins PP?

A

6 weeks

75
Q

What should a PP person do if bleeding occurs?

A

If it increases, rest and call if continues

76
Q

Important referral resources for PP persons

A 
Lactation consultant
Homecare visits
Public health RNs
PT
Early parenting classes
Community support groups
77
Q

Sexuality changes PP

A

Nothing in vagina for 6 weeks

Dryness common –> may need lubricant from 6 weeks to 6 months (oil, silicone, Vit E, coconut oil), vaginal moisturizers

Milk letdown may occur w/ orgasm

Decreased libido common initially for first 3 months

78
Q

Contraception PP

A

Non-hormonal or progesterone only is safe

No OCPs until milk production established (6 weeks)

IUDs can be placed during C/S or after placenta delivers OR at 6 week PP visit

No E2 containing CPs due to increased clot risk

Non-hormonal options –> condoms, lactational amenorrhea, cervical cap/diaphragm, sterilization (essure, tubal ligation, hysterectomy, vasectomy)

79
Q

Infant breastfeeding benefits

A 
Decreased risk of allergies
Infection protection
Decreased risk of DM, asthma, respiratory infections, sepsis, meningitis, ear infections, GI infections, UTIs, obesity, cancer, SIDS, mortality
Meets nutritional needs
Easily digested, well absorbed
Constipation less likely
Less likely to overeat
Not affected by water supply
80
Q

Breastfeeding person benefits

A 
Oxytocin --> involution, bonding
Less blood loss --> delayed return of menses
Delayed ovulation
Reduced cancer risk
Enhances rest
Convenient, economical
Fewer healthcare costs for infant
Less work missed
81
Q

Lactogenesis I

A

Begins during pregnancy through early PP days

82
Q

Lactogenesis I composition

A

Colostrum - thick, yellow, high protein, vitamins, minerals, IgA; establishes normal flora in neonate GI tract; laxative effect for first meconium

83
Q

Lactogenesis II

A

2-3 days PP

84
Q

Lactogenesis II composition

A

Transitional milk - gradual change over 10 days

Decreased IgA, protein

Increased fat, lactose, calories

85
Q

What hormones are important for breastfeeding?

A

Prolactin - stimulates milk production

Oxytocin - milk letdown/milk ejection reflex

86
Q

When is most milk produced?

A

During infant suckling

87
Q

What makes the most milk available?

A

Increased demand w/ frequent & longer nursing

*If colostrum/milk not removed from breast, negative feedback slows production due to decreased PRL

88
Q

Should pumping be done to relieve engorgement?

A

No, amplifies problem

89
Q

Lactogenesis III

A

Mature milk - bluish, thinner, 20 kcal/oz

IGs and antibacterial components present

90
Q

Breast milk make-up

A

Proteins - easily digested, some passed to stool

Carbs - lactose mainly, improves Ca absorption, energy for brain growth

Fats - half of calories in milk; highest in hindmilk for weight gain; vision, brain, NS development

Vitamins - A, E, C, low D; 400 IU for infant w/in first few days; other water-soluble vitamin content depends on breastfeeding person’s intake

Minerals - Fe lower than formula but absorbed 5x as well; breastfed infants maintain Fe stores for first 6 months of life

Enzymes - pancreatic amylase & lipase

Immune components - leukocytes, IGs, secretory IgA

Milk content doesn’t change much w/ breastfeeding person’s diet except for vitamin levels

91
Q

Reasons for formula feeding

A

Keeping breasts sexual
Little experience w/ breastfeeding
Partner/family doesn’t support breastfeeding
Medication use, condition for unsafe breastfeeding
Poor milk supply
Infant won’t latch
Unfavorable past experiences
Work environment doesn’t support breastfeeding
Cultural influences

92
Q

When should feedings be stopped?

A

When infant is non-nutritive sucking

93
Q

Why should bottle feeding and pacifiers be avoided when breastfeeding?

A

Can cause ‘nipple confusion’

94
Q

What indicates a latch problem?

A

Cheek dimpling, smacking, clicking –> sucking on tongue or nipple only

95
Q

How do you assess sucking?

A

Gloved finger in infant mouth

96
Q

Engorgement Interventions

A

Cold packs between feedings
Heat just before feedings
Massage before & after to stimulate letdown
Express/pump a little milk before feeding to soften breast
Feed more often
Wear well-fitting, supportive bra
Pain meds for comfort

97
Q

Nipple pain interventions

A 
Ensure proper latch
Vary infant position
Avoid soap - dries nipples
Begin feeding on less sore side
Nipple shields
Lanolin, hydrogel
Expose to air between feedings w/ milk applied
Return to clinic if concern for yeast infection (burning, itching, stabbing, infant thrush)
98
Q

Flat, Inverted Nipple Interventions

A

Roll nipples
Breast pump to make more erect
Nipple shield

99
Q

Breast Milk Storage Guidelines

A

Countertop (RA) - <4 hrs
Refrigerator - <4 days
Freezer - best is 6 months, up to 12 months (depletes leukocytes)
-thaw in fridge or under warm water; can be kept in fridge for up to 24 hours

Unfinished milk should be used or discarded w/in 2 hrs

OB Nursing (7 decks)

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