Puerperium Flashcards
what is Puerperium
- deliver of placenta till 6-8 weeks post childbirth for pre-pregnancy states to re establish
- Essentially referred to as ‘4th trimester’
involves Routine post-partum management à to ensure the well-being of the mother and baby.
list the three common complaints immediately after surgery
-
Shivering – pathogenesis is unclear – begins in minutes of delivery but shouldn’t last more than 30 mins. maybe d/t anaesthesia
- RX:Conservative
- Cramping – d/t hypertonic uterine contractions . often more sever in multiparous women rx;NSAIDS – spontaneously resolves by 1 week
-
Perineal pain –d/2 swelling, & engorement of perineum. worse if lacerations or episiotomy are present. lasts [[1-2 wks]]
- Ice packs in 24hours à heating pads / Sitz bath in order to drain.
-
Nsaids can also be given
- Given for C/S pain too!
list the following criteria that mus be checked post partum for any abnormalities (12)
- Temperature
- BP
- Pulse
- Blood
- Lochia
- Wounds
- Abdomen
- Fundal height
- Urination –
- Defecation
- Lactation
- Mental status
temperature in pp
Slightly increased d/t dehydration during labour
Returns to normal in 24 hrs
causes of increased temp
- PP infection if T = 100.4/38 + on 2 readings, on days 2-10 PP
- filling of breast milk on 3rd - 4th day
changes of BP during pregnancy
1st trimester – heart works faster to handle ^ vol. BP remqins same = 120/80
2nd trimester – decreases slightly d/t lowered peripheral resistnce as placenta expands rapidly =>heart beats faster = 114/65
3rd trimester – BP back to pre pregnant state
puerperal changes in BP and pathologies
causes pof increased BP in pp
140/90 + could signify PP pre-eclampsia.
Oxytocic meds [Pitocin] > delivery could ^ BP
causes of decreased BP in pp
- [90/60 or below] with dizziness is “Orthostatic hypotension”; could signify hemorrhage.
- Take BP/pulse lying/sitting/standing. Compare values.
- dg Orthostatic if: BP drops 15-20 mmHg and pulse increases 20 bpm or more. Caution for falls.
rx: Needs IV fluids. order for CBC.
how does pp affect pulse
- HR increases in 1st hour.
- 8-10 weeks – return back to pre pregnant state
Rapid pulse or thready pulse – indicates PP Hg or infection
how does bloood change during pregnancy and puerperium
the circulatory system increases its activity by 30-50% during pregnancy
pre-pregnant = 4000cc; pregnant state = 5250cc
- Patient should not be anemic entering delivery
- Possible blood transfusion with large blood loss.
blood volume returns to normal in 1-2 weeks w/ diuresis + blood loss during delivery
- VD – 300 cc
- C/S 500 cc
hematocrit during preg and pp
Non pregnant: HCT=37 - 47% & HGB=12 - 16g/dL
Pregnant: HCT=32 -42 % & HGB = 11.5 – 14g/dL
hematocrit decreases in preg d/2 increased blood vol
HCT drops by 4 %. & HGB drops by 1 g. for every 250cc. of blood loss.
lochi during PP
(shedding of the superficial portion of the decidua basalis)
continues for up to 1 month PP Should be 200-500 ml
different appearance over time
- Lochia rubra – red to brown – 1st few days
- Lochia serosa – pink – 1-2 weeks PP
- Lochia alba – yellow/ white – 2-4 weeks PP
foul smelling= INFECTION
larger than 500ml= HmrhG
wounds cheking
check stitches . check CS
abdominal exam to detrmine feeding after preg in puerperial period
VD
- normal bowel sounds – can eat
C/S =
- bowl sounds are HYPOactive in 1st 8 hours.
- if General anaesthesia used = NPO for 6/8 hours
- BM is observed on the 34d/ 4th day d/t surgery but you can Discharge w/o BM if flatus is present
fundal height changes and assesment in puerperium
palpation immedieltely after delivery by supporting lower segment to prevent uterine inversion. Asses for firmness and position
drops one finger breadth a day for ten days
- delivery - 24 hours= remains at umbilicus
- 1st day PP-1 FB under umbilicus
- Day 10 – back to normal position in pelvic cavity
pathologies of fundal height in PP
causes of false readings
- Increase fundal height d/2 full bladder
- Decrease fundal height from oxytocin release in BreastFeeding ===2 FB under umbilicus on 1 st day
delayed fundal height decrease
- retained placenta/clots decreases effective contraction of uterus not possible ==> Risk of PP Hg!!!
- multiparous pt
- multi-fetuses.
- exhaustion
- C/S involutes slower; d/t surgery & less initiation of BF PP.
peurperal changes to the urinary system
- difficulty urinating d/2 traumatic vaginal delivery=> injury to pudendal nerve
- leads to straining but voiding is still possible
LOSS OF VOIDING- can lead to stasis=> uti/renal failure
- bladder scan shows- over 250ml of urine
- catheterization – may cause dysuria afterwards
LOSS OF BLADDER TONE d/2 anesthesia/ swelling
- reduced urge to void d/2 reduced bladder sensitivity
- urinary stasis=> UTI/ hydronephrosis
- RX W/ DIURESIS & exclude UTI
defacation in the PP period
vaginal delivery: defacation can occur in 2 days
C/S: defacation in 2 days aswell but no eating until the passage of gasses
constipation is common in pp
- d/2 decreased gastric emptying
- reduced movment post labour
- hemmorhoids case painful defacation and aversion
physiology of lactation
- Early pregnancy, ↑ estrogen stimulates growth of milk glands & size of breasts.
- Colostrum: 1-middle of pregnanc(16wks) 2)days 1-3 PP,
- Thin, watery pre-lactation secretion. Rich in antibodies; passes to baby in 1-3 days.
- Breasts begin to get tender; fill up w. milk. in 3rd to 4th day PP D/2
- [let down reflex] =oxytocin released causing > delivery of placenta and estrogen & progesterone lvls drop
- ^ production of prolactin by anterior pituitary
- Milk ducts become distended & fluid turns bluish-white
- Infant suckling on breast produces more prolactin, which in turn stimulates more milk production.
LACTATION-benefits
Advanatages
- Promotes bonding between mother & baby.
- High nutritional value for infant.
- Promotes uterine involution thru release of oxytocin from posterior pituitary.
- Reduces cost of feeding & preparation time
LACTATION CONTRAINDICATIONS
Mom receiving meds not appropriate for Br. fdg. [Lithium]
Exposure to radioactive compounds [thyroid testing]; pump & dump breast milk x 48 hrs. Flush in toilet.
Breast Cancer; HIV
pathologies of lactation (4)
1)Sore/ cracked / bleeding nipples
- d/2 improper positioning or not enough areolar in baby’s mouth
- Rest nipple + apply Lanolin ointment prn or tea bag
2)Engorgement=> breasts hard, painful to touch.
- Warm soaks, hot showers, express milk manually, breast feed q 2-3
- Pumping produces more milk.
- Cabbage leaves; diuretic property.
- nursing bra or tight bra and ice packs x 24-36 hrs
- Analgesics [Tylenol 650 mg. q 4 - 6 hrs.prn
3)Plugged Ductt=>firm nodule under arm; temporarily blocked duct;
- relieved by infant sucking.
- Warm compresses prn.
- Evaluate carefully since may be malignant growth.
4)Mastitis –“inflammation of milk duct/gland d/2 infection
- Poss. antibiotic therapy.
- Manual expression,
- continue to breast feed
- frequent warm compresses
common pathologies of mental status in PP
pp depression
- History of depression and anxiety are leading RFs
- Can last up to 1 year PP
- Screening tool = Edinburgh PP depression tool
- RX: BF helps d/t release of oxytocin IMPROVES MOOD
post partum blues
- feel a sense of abandonment/disappointment d/t decrease in estrogen/ progesterone levels
- sx: No interest in surrounding. anhedonia. Fatigue. Decrease hygiene. Odd food cravings.OCD.Irritable
pp psychosis
- Mania, Halucinations,Delusions, Guilt
weight loss in pp
Average loss at 13 lbs
- 5lbs diuereis
- 2-3lbs – lochial flow
- At 6 weeks à may still be above pre pregnant state.
- stretch marks – appear red at first . fade by 3 to 6 months.
puerperium of the uterus (involution)
- reduces from 1000g to 150g
- back to normal size by 10-12th day (l) 6thwk(google)
what causes failued involution
retained placental tissue
- impairs uterine contraction
- causes post partum hemorrgh
puerperium of cervix
cervical opening closes but cervix never returns to nulliparous state
puerperium of vagina
vagina returns to nulliparous state
oedema resolves by 3rd week
perineum puerperium
swelling and engprment resolves by 1-2 wks
laceration/ episiotomy
- 1st degree:from vagina to base of labia minora
- 2nd: vagina to 1/2 perineum
- 3rd; vag to entire perineum and anal sphincter
- 4th: rectal tissue
- delayed resolution
- ice pack heat bath nsaids
ovariy puerperium
ovulation is delayed until 7-9 weeks d2 high lvls of prolactin
what’s the most imprtant cause of death in puerperium
puerperial bacterial infection of the Genitourinary tract
RF
- premature ROM
- anemia
- hemorrhage
- placental retention
- episiotomy/ C/S
what are the most common causative agents of puerperial infection
- myocplasma
- gram-ve : E.coli/ Klebsiella
- staph aureus
- chlamydia
- clostridia
how does puerperial infection of genital tract present
(least to most severe)
cervicitis
uterine infection
adnexitis
Septic Pelvic Thrombophlebitis
Septicimia
how is puerperial infection rxed
Nutrition and supplements => anemia
broad spec high dose antibiotics
drainage
Thrombophlebitis rx