T3-Maternal Physiologic Changes Flashcards
Return of uterus to non-pregnant state after birth
Involution
Failure of uterus to return to normal size and condition
Subinvolution
Tissue regeneration w/o leaving a fibrous scar at site of implantation
Autolysis
What is the first process of involution?
When placenta is expelled from the uterus
What is the second process of involution?
Autolysis
*makes future pregnancies possible
The fundus is ____ the umbilicus immediately after giving birth
1-2 cm below umbilicus
Within 12 hours after giving birth, the fundus rises to _______ then it descends _____ every 24 hours
Within 12 hours after giving birth the fundus rises to UMBILICUS or SLIGHTLY ABOVE then descends 1-2 cm (FB) every 24 hours
When is the fundus non palpable?
By 2 weeks
Where is the fundus at the 9th or 10th day postpartum?
Back into pelvic cavity and non palpable
By _____ the uterus is the size it was at 20 weeks
24 hours
Where is oxytocin secreted from?
Posterior pituitary
What initiates and maintains UC?
Oxytocin
Contractions control bleeding at the placental site by _____
Compression of blood vessels
What causes the reduction in the size of uterus?
Contractions
How do we document a normal fundus?
- Midline, firm, and at appropriate location for time past delivery
- Document the firmness and position of fundus in relation to umbilicus and abdominal line
Ex: Uterus firm, midline, 2FB below umbilicus
Cramping from oxytocin release after birth (pain r/t UC)
Afterpains
T/F: Afterpains decrease when first breastfeeding
FALSE—afterpains INTENSIFY when first breastfeeding
Who is afterpains more sever in: multigravidas, primagravidas, breastfeeding clients? (SATA)
Multigravidas and breast feeding clients have more severe afterpains
When do afterpains usually resolve?
3-7 days
What are afterpains doing?
Getting the uterus back to prepregnant shape and size
What is the intervention for afterpains associated with UC?
Offer pain meds or non steroid anti-inflammatory med BEFORE breast feeding (ibuprofen)
What are some interventions to enhance contracted state of uterus?
- Empty bladder q2h
- Manual massage of relaxed uterine muscle
- Administer pitocin or methergine PRN
- Breastfeed because it releases oxytocin
How is methergine usually administered: IV or IM?
IM
Does methergine cause decrease or increase in BP?
INCREASE
If the BP is ____ we DO NOT give methergine
Greater than 140/90
What lochia do we see 1-3 days post birth?
Rubra
What lochia do we see 4-9 days post birth?
Serosa
What lochia do we do see 10-14 days post birth?
Alba
What lochia is this: pink/brownish
Serosa
What lochia is this:
Bright red; may have small clots
Rubra
What lochia is this:
Creamy color
Alba
What lochia contains blood, decimal and trophoblastic debris?
Rubra
*If it is large clots, increased bleeding, or foul odor this is ABNORMAL
What lochia consists of serum, leukocytes, tissue debris, and old blood?
Serosa
*If it is excessive bleeding; continues to be bright red at 4-9 days, or has odor this is ABNORMAL
What lochia consists of leukocytes, epithelial cells, mucous, serum, and bacteria?
Alba
*If it is persistent or returns to an earlier stage at the 10-14 day period or has odor then this is ABNORMAL
What are signs of uterine infection?
- Lochia has offensive odor
- Lochia reverts to an earlier stage of color or amount
- Lochia persists beyond normal time
Documentation of bleeding: How much is scant?
Less than 2.5 cm
Documentation of bleeding: How much is small/light
Less than 10 cm
Documentation of bleeding: how much is large/heavy?
Saturated within 2 hours
How should we measure amount of bleeding–what is the better way: cm or weight?
Weight
*1gm=1mL
Hemorrhage in postpartum is defined as blood loss of _____ or greater
500mL
What is the critical time of early hemorrhage?
1 hour past delivery
How often do we assess for hemorrhage after birth?
q15 min X 4 times then q30 min for 2 times, then qhours for 4 times, then q8hours
T/F: Early hemorrhage may be r/t lacerations
True
What is early hemorrhage indicated by?
Continuous trickle of blood in spite of contracted uterus
When is late postpartum hemorrhage?
24 hours or more after delivery
What is late PPH caused by?
Retained fragments of placenta in uterus
*this is why we inspect placenta after it is expelled!!
The cervix is soft ______
Immediately after birth
T/F: The cervix may be bruised and have small lacerations
True
The cervix is ____ open for several days. After 1 week it is the _____ size
2-3 cm open for several days; size of fingertip after 1 week
External cervical os changes from round to slit-like os of multiparous women. T/F: It returns to prepregnant round state after delivery of baby.
FALSE-it will never return to the prepregnant round state
The vagina mucus is thin and without rugae. Why?
Caused by postpartum estrogen deprivation
When does the vagina get to pre pregnancy size?
6-10 weeks after delivery
The perineum may have edema and erythematous. How do we check for episiotomy and lacerations and the healing of them?
REEDA
- Have them lay on side
- Spread butt cheeks apart
- Use a light and check REEDA
What heals better: episiotomy or laceration?
Episiotomy; this has a better approximation of the cut
What does REEDA stand for?
- Redness
- Edema
- Ecchymoses
- Discharge (from suture line; not lochia)
- Approximation of episiotomy
How are lacerations measured?
1st-4th degree
What is a first degree laceration?
Superficial vaginal mucuosa or skin of perineum
What is a second degree laceration?
Deeper tissues including muscles of perineum
What is a third degree laceration?
Same as 2nd but extends to include anal sphincter
What is a 4th degree laceration?
Extends through anal sphincter into rectal mucosa
What is a periurethral laceration?
A laceration in the area of the urinary urethra
*Hurts a lot due to urine being acidic and an open cut
What degree lacerations cannot get a suppository?
3rd and 4th degree lacerations
Supportive tissues of pelvic floor are torn or stretched during childbirth. It takes up to ___ to remain tone. Do ____ to promote tone.
6 months; kegel exercises
Placental hormones decrease rapidly. Estrogen and progesterone levels at lowest within ___.
1 week
Prolactin is up and estrogen is down. What does this mean?
Milk is in but menstrual periods may be delayed
Type I DM mothers may require less or more insulin for several days after birth?
LESS
Prolactin level is ____ than estrogen
Higher
The inverse relationship between estrogen and prolactin appears to _____
Suppress ovulation
*when the cycle comes back the first one will be very heavy but should return to normal after 3-4 cycles
Duration of involution is influenced by ____ and ____
Breastfeeding and strength of sucking stimulus
Prolactin from _____ is responsible for ____
Anterior pituitary is responsible for milk production
Oxytocin from _____ is responsible for ______
Posterior pituitary is responsible for milk ejection or let-down reflex
Nipple stimulation does what?
Release of oxytocin
Describe soft breasts and when do we see them?
1st or 2nd day PP; feels like ear
Describe filling breasts and when do we see them?
3rd or 4th day; feels like nose
Describe engorged breasts.
Breast distention r/t stasis of venous and lymphatic fluid; hard to touch and client complains of pain
Colostrum is secreted first ____ post delivery. It is high in ___ & ____. It is low in ___ & ___.
Secreted first 2-3 days post delivery
High in: Protein and immunologic factors
Low in: Fats and carbs
When is true milk secreted? When is it fully mature? How does it increase?
Secreted: 3-4th day
Fully mature: At about 2 weeks PP
It increases in direct proportion to nutritive infant sucking or pumping breasts
If a woman is not wanting to breastfeed, what should we tell them about?
- No hot showers directly on breasts (stimulates let down reflex)
- Wear tight fitting bra
- Use cabbage leaves
- No nipple stimulation
- Pain meds for engorgement
When does menstrual cycle resume in non-lactating women? what about lactating?
Nonlactating: 7-9 weeks
Lactating: ~6 months
____ and ____ are influenced by breast feeding
Ovulation and menstrual cycle
Due to the increased BV during pregnancy, we can tolerate blood loss. How much blood loss in vaginal birth? c-section?
Vaginal birth: up to 500 mL
C-section: up to 1000 mL
Response to blood loss: There is a fluid shift as uteroplacental circulation is eliminated resulting in _____ circulating volume. Fluid is eliminated by ____ & ____. Output may be ____.
Resulting in INCREASING circulating volume; fluid is eliminated by DIURESIS and DIAPHORESIS; output may be greater than 3000 mL/day
Activation of blood clotting factors and immobility predispose to _____.
What are WBC values?
Predispose to thromboembolism
WBC values high–between 20-25 thousand
*WBC not always conclusive of infection first week
Peristalsis is sluggish r/t progesterone effects as well as decreased muscle tone. What does this mean?
Constipation
Loss of bladder muscle tone and increased capacity leads to ___ and ___ and ___
Retention and stasis of urine and UTI
*there is also decreased sensitivity to fluid pressure because the bladder tone is down/anesthesia effects (this can cause retention and stasis)
What do we teach client to avoid potential UTI?
- Empty bladder q2h AT LEAST
- Symptoms are dysuria and frequency with overflow (feel urge to urinate frequently but don’t empty the bladder)
- Does chloasma disappear PP?
- Does hyper pigmentation of areolae and line nigra disappear PP?
- Does striae gravidarum go away PP?
- Chloasma: disappears
- Hyperpigmentation of areolae and linea nigra: May not regress totally but it DOES get lighter
- Stretch marks DO NOT go away (get lighter tho)
Rh- mom and rh+ baby and no isoummunization occurs then RhoGAM is given within ____ of delivery
72 hours
Immediately after birth, the uterine fundus is _____. After an initial rise, the fundus descends _____. Fundus should not be palpable after ____.
Below umbilicus; descends 1-2cm/24hr; not palpable after 9-10 days post birth
The uterus must remain _____ to prevent excessive bleeding
Contracted
Bleeding or fundus is high. What do we FIRST suspect?
Full bladder
Activation of blood-clotting factors, immobility, and sepsis predispose to ______
Thromboembolism
Marked diuresis, decreased bladder sensitivity, and over distention of bladder can lead to problems with urinary elimination especially ____
UTI
