Postpartum Physiological Adaptations Flashcards
What is the average length of time for return to non-pregnant physiology?
6 weeks
What are the most significant risks during postpartum period?
Hemorrhage, infection, shock
Why are uterine contractions important after delivery?
Minimize bleeding
Define afterpains
Uncomfortable uterine cramping after delivery
What happens to estrogen after delivery?
It drops
Effects of decreased estrogen in PP
Breast engorgement (increased PRL), diaphoresis, diuresis, less vaginal lubrication
What happens to progesterone after delivery?
It drops
Effects of decreased progesterone PP?
Increased body muscle tone
What happens to blood glucose after delivery & why?
It drops due to decreases in placental enzyme insulinase
What happens to hCG after delivery?
It disappears quickly but can be detected up to 4 weeks PP
When does ovulation return in breastfeeding persons & why?
About 6 months PP due to suppression by PRL
What maintains PRL levels in breastfeeding persons?
Breastfeeding frequency, length of feeds, supplement use, infant suck
When does ovulation resume in non-breastfeeding persons?
7-9 weeks w/ menses resuming by 12 weeks
What are important components of PP assessment? (5)
VS, uterine firmness, uterine location relative to umbilicus, uterine position relative to midline, amount of vaginal bleeding
VS monitoring PP
BP, HR q15mins for first 2 hrs
Temp q4hrs for first 8 hrs, then at least q8hrs
BUBBLE: focused PP assessment
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
PP labs
Urinalysis, CBC (Hgb, HCT, WBC, platelet), Rubella titer, Rh status (if unknown)
Uterine involution
Rapid reduction in uterus size & return to pre-pregnant state
What enhances uterine involution?
Uncomplicated birth, complete expulsion of placenta/membranes, breastfeeding, early ambulation
How does breastfeeding enhance uterine involution?
Stimulates exogenous oxytocin release
Uterine subinvolution
Involution does not happen properly
Risk of improper uterine involution
PP hemorrhage
Uterine exfoliation
Healing of placenta site, important part of involution
What causes uterine involution?
Contractions
How do you assess uterus PP?
Cup uterus above symphysis pubis and palpate fundus
PP uterine assessments
Fundal height
Uterus location/position
Uterine consistency
How much does the fundal height change per day?
About 1 cm per day (one fingerbreadth)
Where should the fundus be 1 hour after delivery?
Umbilicus
When should the uterus no longer be palpable PP?
About 2 weeks
What should you do if the fundus is boggy?
Gently massage it in a circular motion
*If it doesn’t become firm, continue massaging and notify provider
How do you document PP fundal height?
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)
Where is the fundus and what does it feel like immediately after delivery?
1-2U and like a grapefruit
What can enhance involution/after pain?
Multiparas due to repetitive stretch of myometrial fibers
Overdistended uterus - multifetal, LGA, polyhydramnios, retained clots
Breastfeeding due to higher oxytocin
When does involution/after pain typically begin to subside?
By 3rd day = mild discomfort
Nursing interventions for involution/afterpain
Analgesics - ibuprofen, narcotics if necessary; facilitates milk ejection/letdown
Position changes –> prone w/ blanket under abdomen/pelvis
Heat
Lochia
Uterine debris ejected after birth
Typical lochia changes
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
What causes fundal bogginess?
Uterine atony
What can cause uterine atony?
Blood clots, retained placenta
Why is it important for the birthing person to void after birth?
Bladder distention can displace uterus and stimulate atony
Assessment of PP lochia
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
Manifestations of abnormal lochia
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)
Cervical changes PP
Internal os closes, soft, external os may remain slightly open (1 cm) & slit-like
Potential edema, bruising, small lacs
Vaginal changes PP
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
Nursing interventions for perineal tenderness, lac, episiotomy
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
Why can birthing persons tolerate substantial blood loss during birth?
Hypervolemia during pregnancy
CV changes PP
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
BP changes PP
Typically minimal, transient increase
If low, possible hemorrhage
If high, possible PP HTN
Orthostatic hypotension possible for 48 hrs PP
Puerperal bradycardia
HR as low as 40 bpm, common
Assess tachycardia
Fever PP
Normal to elevate to 100.4F for 24 hours
If >24-48 hrs, possible infection
GI changes PP
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
Urinary Tract changes PP
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
Nursing assessments of urinary tract PP
Ability to void
Bladder elimination pattern
Bladder distention –> can displace fundus/uterus
Frequent voiding <150 mL –> retention w/ overflow
MSK changes PP
Decreased relaxin –> joints/ligaments normalize
Increased muscle tone as progesterone decreases
Diastasis recti resolves w/in 6 weeks –> recommend gentle exercises to strengthen
Neurologic changes PP
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
When can ovulation resume for breastfeeding persons?
8 weeks to 18 months, average 6 months
Weight loss PP
10-12 lb at birth
9 lb over first 2 weeks
Adipose tissue lost slower; 6-12 months to reach pre-pregnancy weight
Typical hospital stays PP
Vaginal –> 1-2 days; more frequent assessments closer to delivery
C/S –> 2-4 days (3 nights), post-op pts
Important labs to review from prenatal record in PP period
GBS status, HepBsAg status, syphilis screen
Immune system review PP
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
PP Assessment Schedule (varies)
q15m for 1 hour, then
q30m for 1 hour, then
q1h for 2 hours, then
q4h for 24 hours, then
q8h until discharge
Breasts PP
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
What should DTRs be PP?
1-2+ (mostly normal)
Important orders needed in EHR before discharge
Breast pump, contraception, narcotics, home visits
Four traditional positions for breastfeeding
Football, Cradle, Modified Cradle, Side-lying
Comfort measures PP
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
Breastfeeding education
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
Relief of breast engorgement
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)
Nipple care during breastfeeding
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
Education for persons not planning to breastfeed
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
Exercises for PP birthing person
Pelvic tilt
Kegels
No abdominal exercises for C/S persons for 4-6 weeks
Caloric needs of lactating persons
Extra 450-500 kcal/day
Caloric needs of non-lactating persons
1800-2200 kcal/day
How long should birthing persons take prenatal vitamins PP?
6 weeks
What should a PP person do if bleeding occurs?
If it increases, rest and call if continues
Important referral resources for PP persons
Lactation consultant Homecare visits Public health RNs PT Early parenting classes Community support groups
Sexuality changes PP
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
Contraception PP
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)
Infant breastfeeding benefits
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
Breastfeeding person benefits
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
Lactogenesis I
Begins during pregnancy through early PP days
Lactogenesis I composition
Colostrum - thick, yellow, high protein, vitamins, minerals, IgA; establishes normal flora in neonate GI tract; laxative effect for first meconium
Lactogenesis II
2-3 days PP
Lactogenesis II composition
Transitional milk - gradual change over 10 days
Decreased IgA, protein
Increased fat, lactose, calories
What hormones are important for breastfeeding?
Prolactin - stimulates milk production
Oxytocin - milk letdown/milk ejection reflex
When is most milk produced?
During infant suckling
What makes the most milk available?
Increased demand w/ frequent & longer nursing
*If colostrum/milk not removed from breast, negative feedback slows production due to decreased PRL
Should pumping be done to relieve engorgement?
No, amplifies problem
Lactogenesis III
Mature milk - bluish, thinner, 20 kcal/oz
IGs and antibacterial components present
Breast milk make-up
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
Reasons for formula feeding
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
When should feedings be stopped?
When infant is non-nutritive sucking
Why should bottle feeding and pacifiers be avoided when breastfeeding?
Can cause ‘nipple confusion’
What indicates a latch problem?
Cheek dimpling, smacking, clicking –> sucking on tongue or nipple only
How do you assess sucking?
Gloved finger in infant mouth
Engorgement Interventions
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
Nipple pain interventions
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)
Flat, Inverted Nipple Interventions
Roll nipples
Breast pump to make more erect
Nipple shield
Breast Milk Storage Guidelines
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
