Postpartum: Sherpath Flashcards
Postpartum
Descent of the Uterine Fundus: Three processes
Contraction of the muscle fibers
Catabolic processes
Regeneration of uterine epithelium
Subinvolution
is a slower than expected return of the uterus to its non-pregnant size and consistency
What may delay the uterus from returning to it pre-pregnancy state?
Retention of placental fragments
Pelvic infection
May not be evident until well after discharge
Involution can be evaluated by measuring the descent of the fundus.
About 1 cm per day
14 days after childbirth, the fundus should no longer be palpable.
“After pains” or intermittent uterine contractions, cause discomfort for many women (multiparas, breastfeeding)
Bubble Assessment: B (Breast)
Colostrum excretion
Assist mom with putting baby to nipple within first hour of birth
Assist with breastfeeding positions, techniques
Bubble Assessment: U (Uterus)
Location of fundus above baseline level Fundus displaced from midline Excessive lochia Bladder discomfort Bulge of bladder above symphysis Frequent voidings of less than 150 mL of urine, which may indicate urinary retention with overflow
Bubble Assessment: B (Bowel)
Push fluids
Assist to toilet
May need stool aids
Bubble Assessment: B (Bladder)
Monitor for distention
Assess for retention
Displaced fundus
Bubble Assessment: L (Lochia)
Lochia rubra Lochia serosa Lochia alba Color Amount, type, and odor Foul odor suggests endometrial infection
Bubble Assessment: E (Episiotomy)
Pericare
Infection prevention
Focused Assessment: Perineum
First-degree: Involves the superficial vaginal mucosa or perineal skin.
Second-degree: Involves the vaginal mucosa, perineal skin, and deeper tissues, which may include fascia and muscles of the perineum.
Third-degree: Same as second-degree lacerations but involves the anal sphincter.
Fourth-degree: Extends through the anal sphincter into the rectal mucosa.
Perineum: After childbirth may be edematous and bruised
Episiotomy or trauma
Healing takes up to 4–6 months
Focused Assessment: Vagina
It takes 6–10 weeks for the vagina to regain its non-pregnant size and contour
Focused Assessment: Fundus and Lochia
Lower extremities Homan’s sign, +/- Edema and deep tendon reflexes Vital signs Blood pressure Orthostatic hypotension Pulse Respirations Temperature Pain
Focused Assessment: Periurethral Area
A laceration in the area of the urethra may cause women difficulty urinating after birth. An indwelling catheter may be necessary for a day or two.
Focused Assessment: Vaginal Wall
A laceration involving the mucosa of the vaginal wall.
Focused Assessment: Cervix
Tears in the cervix may be a source of significant bleeding after birth.
Provide Comfort Measures
Ice packs Sitz baths Perineal care Topical medications Positioning Analgesics Rest
Normal Lochia Rubra(1-3 days)
Bloody; small clots; fleshy, earthy odor, red or red/brown
Normal Lochia Serosa (4-10 days)
Decreased amount; serosanguineous; pink or brown-tinged
Normal Lochia Alba (11-21 days)
Further decreased amounts; white, cream, or light yellow
Abnormal Lochia Rubra
Large clots; saturated perineal pads; foul odor
Abnormal Lochia Serosa
Excessive amount; foul smell; continued or recurrent reddish color
Abnormal Lochia Alba
Persistent lochia serosa; return to lochia rubra, foul odor; discharge continuing
Postpartum changes by system: Neurological
Bilateral and frontal headache common due to changes in fluid and electrolyte balance
Spinal headaches due to spinal anesthesia
Blurred vision, photophobia, and abdominal pain may indicate preeclampsia
Postpartum changes by system: Cardiovascular
Transient increase in maternal cardiac output after childbirth
Excess plasma volume is eliminated by diuresis and diaphoresis
Gradually cardiac output decreases and returns to normal in 6–12 weeks
increased clotting factors predispose the postpartum woman to clot formation
Postpartum changes by system: GI
ecreased food and fluid intake during labor
Reduced muscle and bowel tone
Fear of pain during defecation
First stool 2–3 days post birth
Postpartum changes by system: GU
Increased bladder capacity and decreased sense to fluid pressure may result in urinary retention.
Stasis of urine allows time for bacteria to grow and can lead to urinary tract infection.
The distended bladder displaces the uterus and can interfere with uterine contraction and cause excessive bleeding
Postpartum changes by system: Musculoskeletal
First 1–2 days after childbirth, muscle fatigue and aches
Abdominal wall: Diastasis recti
Reduction in musculoskeletal discomfort: Exercises to strengthen the abdominal muscles
Good posture
Body mechanics
Postpartum changes by system: Integumentary
Skin gradually returns to non-pregnant state: Decrease in hormone levels Stretch marks (striae gravidarum) fade: Do not disappear Loss of hair: Normal response to hormone changes Begins 4–20 weeks after delivery Regrown in 6–15 months
Postpartum changes by system: Endocrine
Hormones: Human chorionic gonadotropin is present for 3–4 weeks
Resumption of ovulation and menstruation: Breastfeeding may delay the return of ovulation and menses
Ovulation may occur before the first menses
Lactation: Prolactin initiates milk production within 2–3 days of the birth
Postpartum Weight Changes
Approximately 5.5 kg (12 lbs) is lost during childbirth
Fetus, placenta, amniotic fluid
Another 4 kg (9 lbs) is lost over the next 2 weeks
Another 2.5 kg (5 lbs) is lost by 6 months post delivery
Adipose tissue is used for energy expenditure during labor and breastfeeding
Postpartum Psychosocial Assessment
Mild depression: “baby blues”, lasts a few days to a couple of weeks PP
Affects 70–80% of new mothers
PP Depression begins generally in the first week postpartum and can last 6 months or longer, debilitating
Should not last longer than 2 weeks
Must be distinguished from postpartum depression or postpartum psychosis
Panic disorder
Tachycardia, shortness of breath
Fear of dying or “going crazy”
Postpartum obsessive-compulsive disorder
Consuming thoughts of harming the baby
Posttraumatic stress disorder
Women perceive childbirth as a traumatic event
Postpartum Psychosocial Assessment: S/S
Feelings of sadness, crying Loss of pleasure in usual activities Anxiety, agitation or irritability Feelings of guilt Fatigue, sleep disturbances Difficulty concentrating or making decisions Depression (may not be present at first) Suicidal thoughts
Early Post Partum Hemorrhage
First 24 hours
Cumulative blood loss of 1000 mL or greater
Late Post Partum Hemorrhage
From 24 hour up to 6 weeks postpartum
Sub-involution of the uterus
Retained placental fragments
S/S of Post Partum Hemorrhage
A uterus that does not contract or does not remain contracted
Large gush or slow, steady trickle, ooze, or dribble of blood from the vagina
Saturation of one peripad per 15 minutes
Severe, unrelieved perineal or rectal pain
Tachycardia
Collaborating with the provider: PPH
Uterine massage
Check bladder for distention.
Laboratory studies
Administer fluids and medication.
PREVENTION: PPH
Identify predisposing factors.
Hypovolemic Shock
During and after birth, women can tolerate a blood loss approaching that of blood added during pregnancy
1500–2000 mL
Compensatory mechanisms maintain the blood pressure so that vital organs are perfused
Shock occurs with excessive blood loss
Uterine Atony: Manifestations
Fundus is difficult to locate
“Boggy” or soft feel to the fundus
Becomes firm when massaged
Excessive lochia and clots
Uterine Atony: Management
Measures to contract the uterus
Provide fluid replacement
