pp care + complications Flashcards
VS changes
Temp elevated (100.4) up to 24 hr then afebrile, can also be elevated 24 hr after milk production
BP elevated then normal
Bradycardia 6-10 days
VS changes - abn
High BP: preE, essential htn or chronic, renal issues, anx
Treat with procardia, labetolol, aldomet; MgSO4 IV (2g/hr for 24-48 hr, at least 24)
Tachy: hard labor and birth, hemorrhage; rule out infection
Marked tachypnea: resp disease, pulmonary edema
Temp > 100.4: infection
CV changes
CO decrease 30% in 2 wk -> normal by 6-12wk
D/t diuresis (first few days): decrease ECF and weight loss
Failure to do this = pulmonary edema and heart problems (crackles in lungs)
Respiratory changes
Lungs clear, non labored
Eupnea: tachypnea = fever, pain; bradypnea = resp compromise, med, anesthesia
Watch for fluid overload: bolus, pitocin, MgSO4
Neuro changes
HA: most common complaint, fluid shifts 1st week after, leakage of CSF d/t epidural or spinal (blood patch), chronic or gestational htn, preE, stress and fatigue (rest)
Visual: spots, blurring, bright lights
Treat = caffeine, acetaminophen
Nutrition changes
Increase Fe (supplement depending on EBL), may need to continue prenatal vit
Breast feed: increase 300kcal
Non breast feed: decrease 200kcal
Lab value changes
Non patho leukocytosis in 1st week (wbc = 25000 - 30000)
EBL: 2-3% hct = 500mL
Plasma = prepreg state in 4-6 wk PP
Plt normal by 6 wk
Blood values = prepreg state by week 6
Ovulation/menstruation
Non breast feed: o = 70-75 days; m = 7-12wk
Breast feed: m = delayed 3+ mo (exclusive or not), not birth control (can ovulate without bleed)
Weight change
Decrease 10-12 lb (baby, placenta, amniotic fluid
PP diuresis = 5lb
May return to prepreg by 6-8 wk depending on diet and exercise
PP assessment
Breasts
Uterus/abdomen
Bowel
Bladder
Lochia
Episiotomy, lacerations, abd incision
Homan’s sign
Emotions
PP assessment - breasts
Size and shape, abn, red areas, enlarge, fullness d/t milk
Nipples: cracks, fissures, soreness, inversion
how is feeding going? observe, praise and guidance, prevent issues (+ non breastfeeding)
blocked duct = hard in one area -> massage while feeding, heat before, empty with each feed
Non lactating - suppress
Well fitting bra or ace wrap binder, cold compress or cabbage leaves, anti inflam meds, no warm water on breasts, no stim
Lactation
Feed q1.5 - 3hr (8-12x/day)
10-20 min each breast (not as long on 2nd)
Heavy ok; not read, hard, sore
No OH 2hr before nursing, only occasional use (pump and dump)
Cradle position, modified cradle, football hold (c/s), side lying (c/s, dont fall asleep), stomachs flush, feed horizontally not from angle above
Good latch = fish shape mouth (shouldn’t head smacking -> break latch, stroke chin to open mouth more, upper lip flared up lower flared out)
Nipple shield = flavor non aggressive feeder
Allow nipples to dry to prevent breakdown
Concerns about breast feeding
Pain (nipple tenderness -> poor latch), embarrassment, feel tied down, unequal responsibilities (dads left out)
Getting enough milk: edges of mouth, 6-8 wet diapers/day, swallow, softer breasts; s/s = soft breast, audible swallowing
7 days = 1BM with each feed
Breast feed difficulties - insufficient milk
6-8 diapers, increase fluid intake to 2L/day
Breast feed difficulties - sore nipples
Good latch, lanolin cream, express breast milk and let dry (open to air), begin nursing on less sore side
Breast feed difficulties - flat nipples
Roll with fingers, use shield
Breast feed difficulties - plugged ducts
Freq nursing, change positions, manual massage, warm compress, pump, start on affected side (aggressive baby), prevent!, mastitis
Pressure from purse strap, infant sling, car seat belt can cause recurring
Mastitis
Sudden onset, chills, fever, malaise, red, painful, swollen areas, possible drainage, unilateral
Warm compress and analgesics, 7-10 days abx (pcn), take all!, supportive bra all the time to avoid milk stasis (no underwire), HH, prompt attention to blocked ducts, good positioning and latch, supply and demand, report flu like S, regular complete emptying
continue to breastfeed!!
Mastitis - milk stasis
Failure to change infant position to allo emptying of all lobes
Failure to alternate breasts at feedings
Poor suck
Poor let down
Mastitis - bacteria
Poor HH
Improper breast hygiene
Failure to air dry breasts after breastfeed
Use of plastic lined breast pads that trap moisture against nipple
Mastitis - breast/nipple trauma
Incorrect positioning for breastfeeding, poor latch, failure to rotate position on nipple, incorrect or aggressive pumping technique, cracked nipples
Mastitis - obstruction of ducts
Restrictive clothing, constricting bra, underwire bra
Mastitis - feeding changes
Attempted weaning, missed feed, prolonged sleep (through the night), favorite side of nipple soreness
Mastitis - lowered defenses
Stress and fatigue
Engorgement
Venous stasis
Hard and painful d/t soreness
Gradual onset, entire breast affected (bilateral)
No high fever
Dont miss feeding, hand express or pump to soften before feed, nurse 8-12x/day 10-15min/breast (feel soft and empty - switch side), warm compress before feed for let down, cold applications btw feedings to slow milk production (ice), well fitted nursing bra 24hr/day, cabbage leaves (decrease edema), feed more frequently (q1-1.5hr)
Weaning
Sub 1 cup feed for 1 cup breast over few days to a week so breasts gradually produce less
Over several weeks, sub more
Slow wean prevents engorgement, allows infants to alter eating methods at own rates, provide time for psych adjust (bonding time and dependence)
PP assessment - abd
Loose and flabby but responds to exercise. Uterine ligaments gradually return to prepreg state, diastasis recti abd (abd muscles separate, sx, overdistended abd, linea alba stretched, bulge, PT, resolve on own)
Striae colors (red = new, silver = older)
Assess for after pains: intermittent uterine contractions with uterine involution, resting prone with pillow under abd helps keep uterus contracted, Motrin 600mg po q8hr prn for cramps (not if plt <70,000, careful with preE)
c/s = reeda
PP assessment - uterus: involution
Decrease by 100g, spongy layer of decidua sloughed off, basal layer differentiates into 2 layers (outer sloughs off, inner begins new endometrium), placental side heals by exfoliation
1 hand on fundus other on symphysis pubis: expel clots and firm fundus
Uterus: endometritis
PP uterine infection
Involves lining of uterus (tender, temp 100.4+, chills, foul smelling lochia
Rf: c/s, PPROM, prolonged labor, multiple vaginal exams, FSE/IUPC, instrument assisted deliveries, manual removal of placenta, chorioamnionitis
Treat: broad spectrum abx until culture and sensitivity, continue until afebrile 24-48hr
Fundal assessment
Position related to umbilicus (6-12hr PP) and midline
Firm or boggy
Involution: contracts 1 finger/day
Fundus descends 1cm/day until in pelvis on 10th day (palpable until)
Massage: firm = well contracted (limit bleed); boggy = spongy or soft
Void = higher in abd or off to 1 side
Atony = more bleeding, increase oxytocin, multiparty, multiples, LGA, red haired women
FF U/-1 = firm fundus, 1 finger under umbilicus
PP assessment - bowels
Sluggish: progesterone, decreased muscle tone, birth process, anesthesia of c/s
Episiotomy, lacerations, hemorrhoids may delay: fear of tear, stool softeners, tucks pads for hemorrhoid itching and coolness
1st BM = day 3
PP assessment - bladder
Increased capacity during pregnancy, swelling and bruising of tissues around urethra, decrease in sensitivity to fluid P, decrease sensation of bladder filling (esp with epidural), output increases bc puerperal diuresis (must rid 2000-3000mL ECF), increased r/o infection (dilated ureters and renal pelvis), monitor adequacy of elimination/distention (I+O prn)
UTI s/s and treatment
PP assessment - lochia
After delivery, vaginal discharge of blood, mucus, atrophied uterine cells
Debris in uterus discharged via lochia: rubra = red (2-4 days), serosa = pink (4-10 days), alba = white (10-20 until cervix is closed)
Uterus prepreg size by 5-6 wk PP
Amount - PPH, shouldn’t saturate in less than 1 hr
PPH
Uterine atony!, lacerations of genital tract (fundus firm, no clots, free flow bleed), episiotomy, retained placental fragments, vulvar, vaginal, sub peritoneal hematoma; uterine inversion (prolapse of uterus, placed back in per MD), uterine rupture (hysterectomy), problems of placental implantation, coag disorders (low plt, DIC)
PPH s/s
Excessive or bright red bleed, boggy without response to massage, abn clots, increased temp, any unusual pelvic discomfort or backache, persistent bleed in presence or firm uterus, increase in fundus level, pulse increased, BP decreased, hematoma or bulge/shining skin in perineal area, decreased LOC
PPH prevent
Massage, assess perineum, freq void or cath, hct levels, eat foots high in Fe (oral meds), rise slowly to minimize orthostatic hypoT if blood count low
PPH meds
Oxytocin: after placenta, and early PP
Methylergonovine maleate: no htn
Carboprost: diarrhea
Misoprostol: can follow with oral drugs
Cervical and vaginal changes
Cervix: spongy, flabby, maybe bruised
External os: lacerations, irregular, slowly close, shape change to lateral slit (diaphragm refitted)
Vaginal may be edematous, bruised, small superficial lacerations, size decrease in rugae reappear 3-4wk, prepreg state 6wk, initial healing of episiotomy lacerations 2-3 wk, complete = 6mo
Lacerations
1st degree = 1 layer, 2nd = muscle (episiotomy), 3rd = to sphincter, 4 = into rectum
position to assess: sidelying with superior leg elevated
Peri assess
Redness
Edema/swell
Ecchymosis or bruising
Discharge
Approximation
Peri care
Ice packs (1st day then warm), topical anesthetic s, waffle cushions, surgitator, sitz bath, no enemas or suppositories for 3rd and 4th, avoid C
Hemorrhoid care
Sitz bath, topical anesthetic ointment, rectal suppositories, witch hazel pad, epifoam, tucks
Side lying position, avoid prolonged sit
Adequate fluid intake and stool softeners
Abd incision care closure
Staples: remover, open to air, REEDA, shouldn’t look angry, stern strips after
Dermabond closure = glue
Care after c/s
Decrease resp complications: IS, deep breathe, ambulating
Rest btw care of self and infant
Pain manage: Percocet, Lortab, Motrin, Tylenol
Decrease gas pains: ambulating, mylicon 80mg chews (dont swallow)
PP assessment - Homans sign
Assess thrombophlebitis
Dorsiflex foot, assess pain when walking
Assess calf for size, red, warm
Pain in leg, inguinal, lower abd
Edema of extremity: usually 1 sided
Temp change of extremity
Pain with palpation
Prevent: avoid prolonged sit/stand, dont cross legs, freq breaks with car trips, SCDs, early ambulating (decrease constipation, resp dysfunction, thrombophlebitis, general well being)
Taking in
1-2 days after
Passive, dependent, follow suggestions, hesitate to make decisions
Work through reality vs fantasized experience of childbirth
Food and rest
Taking hold
2-3 days
Ready to resume control of body, mothering
Continue to provide assurance with learned skills as new mother
Becoming a mother
Learn mothering behaviors
Anticipatory: begin in preg, role models, fantasize, role play, expectations
Formal: birth, role guided by others in social system
Informal: develop new role as it fits in her lifestyle, future parenting goals
Personal: internalize role and experiences harmony of self, confidence and competence in her role as mother
Adjustment rxn with depressed mood
50-80%
PP blues
Transient period or depression, 3-5 days to 6wk, usually resolves 10-14 days, more severe in 1st time mothers
Adjustment rxn with depressed mood - s/s
Mood swings (mild depression interspersed with happy feelings), self limiting, irritable/overly sensitive, episodic tearfulness without cause, difficulty sleeping, feeling of being let down, anx
Adjustment rxn with depressed mood - rf
Rapid hormone changes, fatigue, discomfort, overstim, insecure, anx; emotional let down after birth, grief to loss of fantasized vaginal birth experience if c/s
Adjustment rxn with depressed mood - nc
Anticipatory guidance, validate feelings and reassurance, rest (quiet time) and good nutrition, parenting reference materials, support network and inclusion of fam, open visiting hours and rooming in
PP major mood disorder
PPD
3-30%, increase with hx of depression
Greatest occurrence around 4th week, can occur up to 1 year after birth
No mood swings -> depression
Can contemplate suicide (escape and protect baby), major depression if left untreated
PPD - rf
1st preg, ambivalence, hx of previous PPD or D, low support, dissatisfaction with self or body image, adolescent, socioeconomic hardship, hx of abuse, scared of meds
PP psychosis
ER
1-2 per 1000 births, usually evident w/n 1-3 mo
Treatment allows improvement in 2-3 mo
S: agitation, hyperactive, insomnia, confusion, difficulty remembering or [], delusions or hallucinations/illogical thinking, sluicing/infanticide
Nc: PPD and psychosis
Refer to mental health professional, help parents understand lifestyle change and role demands, anticipatory guidance, dispel myths about perfect mom/baby, educate about S, foster and adjustments, assess dependence, screening tool, community resource info
PPD: treat
CBT is first line
Sertaline 1st
Paroxetine 2nd
Prozac (no breast feed)
PP psychosis: treat
CBT is first line
Lithium, antipsychotics, electroconvulsive therapy with psychotherapy (reset brain imbalances), possible removal of infant, assess social support
Attachment/bonding
Gradual exploration of newborn: fingertips, palms (larger body surface), enfold in hand and arm (holding)
En face: f2f, direct eye contact, maternal response
Engrossment: absorption, interest, preoccupation, paternal response
Siblings: let them help, gather supplies, tour house
Attachment/boding - bunch of shit
Incorporate family foals in care plan
May postpone eye prophylaxis for 1hr after delivery
Provide private time for the family to become acquainted
Encourage kangaroo care
Encourage mother to tell birth story
Encourage sibling involvement
Prep parents for potential problems with adjustment
Initiate and support measures to minimize fatigue
Help parents identify, understand, accept feelings
Cultural support
Individualize care
Assess level of acculturation and assimilation to western culture
Involve cultural foods and familiar customs when possible
Rest and activity
Encourage freq rest: sleep when baby sleeps, encourage outside help when offered
Resume activity: avoid heavy lifting, avoid freq stair climbing, avoid strenuous activity
Sexual activity
Resume after episiotomy healed and lochia stopped: usually 4-6 wk
Lubrication may be required
Contraception
Potential limiting factors: fatigue, infant demands
Discharge criteria
Stable VS, appropriate involution of uterus, appropriate lochia amount w/o s of infection, knowledge of s of infection, episiotomy or lacerations well approximated, ability to perform pericare and apply meds as ordered, void and pass flatus, take fluids and food without difficulty, identify s of PPD and resources, review teaching materials and cares for self and baby, display appropriate interaction with baby, infant safety, rubella non immune or equivocal status, RhoGAM (- mom, + baby, - direct Coombs)
PP resources
Home health
Phone follow up: best time to call
PP classes: breastfeeding, BCLS
Support groups
