T5: Postpartum Family Flashcards
involution
the rapid decrease in the size of the uterus as it returns to its non-pregnant state; begins with the placenta is expelled
when feeling for the fundus what is your landmark
the umbilicus
right after delivery where is the fundus
two fingers below the umbilicus
12 hours after delivery where is the fundus
one finger above the umbilicus
24 hours after delivery where is the fundus
at the level of the umbilicus
after 25 hours the fundal height…
decreases approximately 1cm/day
Subinvolution
failure of the uterus to return to non-pregnant state
what are the two most common caused of subinvolution
-retained placental fragments
-infection
what group has more pain after birth and why
Multigravidas have MORE PAIN after birth because their uterus has lost its elasticity, so it needs to work harder to stay contracted.
placental site
where the placenta detaches; leaves a wound in the uterus and it heals by the uterus contacting on itself to control the bleeding
what is the drainage from the placental site called
lochia (looks like blood but doesnt clot)
lochia
discharge from the uterus that consists of blood from the vessels of the placental site
Lochia rubra
red in color, seen from day 1-3
lochia serosa
pinkish in color, seen in day 3-14
lochia alba
yellow to white in color, seen in day 14 up to 6 weeks
amount of lochia: scant
less than 1 inch (2.5cm) on menstrual pad in an hour
amount of lochia: light
less than 4 inches (10cm) on menstrual pad in an hour
amount of lochia: moderate
less than 6 inches (15 cm) on menstrual pad in an hour
amount of lochia: heavy
saturated pad in an hour
amount of lochia: excessive
menstrual pad saturated in 15 minutes
how to do a fundal check
Place hand over symphysis pubis because you can prolapse the uterus (push it out)
what can a distended bladder do to the uterus
can shift the uterus to the side and prevent uterus from staying contracted
A flaccid fundus indicates
uterine atony
what should be done for a flaccid fundus (uterine atony)
should be massaged until firm; a tender fundus indicates infection
cervix remains open until
day 6
what hormones decrease and which ones increase after delivery
estrogen and progesterone decrease
prolactin and oxytocin increase
Initially the opening of the vagina (introitus) is…
edematous and erythematous
episiotomies and laceration should be healed by
week 6
teaching for episiotomies and lacerations
o Teach mom to make sure the area is kept clean and dry to prevent infection
o Icepacks to help with swelling
first degree laceration
laceration that extend through skin and structures superficial to muscles
second degree laceration
laceration that extend through muscles to the perineal body
third degree laceration
laceration that extend through the anal sphincter muscle
fourth degree laceration
laceration that also involves the anterior rectal wall
pelvic muscular support
- Since the pelvic floor is weak, the patient may have incontinence of urine
- Encourage Kegal exercises to strengthen pelvic floor
estrogen and progesterone levels are lowest when
1 week post partum
oxytocin is for…
“let down” reflex of milk or ejection
prolactin is for
production of milk
ovulation takes longer in women who
breast feed
what does elevated serum prolactin levels in breast feeding women do
supressed ovulation
mature milk production begins
3 days after delivery
When is colostrum present?
16 weeks (baby feeds on this for the first 3 days after delivery)
If mother chose not to breast fees, ovulation can occur in
27 days
if a mother choses not to breast feed what should be done
no stimulation of the breast
o Encourages to wear a tight bra and put cabbage in the bra to reduce pain
WOMEN MAY OVULATE WITH OUT MENSTRUATING, SO…
BREAST FEEDING SHOULD NOT BE CONSIDERED A FORM OF BIRTH CONTROL
Diuresis usually begins within
first 12 hours after birth
GI system interventions after delivery
Clients are usually hungry after birth
-Constipation can occur so stool softener (like Colase) is prescribed
o We want to avoid constipation because it can cause a suture to open
o Hemorrhoids are common
Breasts continue to secrete colostrum for
the first 48-72 hours after birth
Decrease in estrogen and progesterone after birth stimulates
increased prolactin levels which promotes breast milk production
Breasts become distended with milk on the third day so…
o Breast feeding relieves engorgement
Breast care for NON-breast-feeding mothers
o Avoid stimulation
o Apply breast binder, snug fitting bra, apply ice, and mild analgesic for engorgement
CV system post partum
Blood volume loss after delivery, however everything goes back to normal at the end of 6 weeks
o Check CBC after delivery to see hoe the patient compensated the loss (hematocrit, WBC, coagulation factors)
respiratory system post partum
-Decrease in intra-abdominal pressure, mom can breathe easier now
-Decline in progesterone causes the PaCO2 to rise
immune system post partum
Mild suppression during pregnancy resolves gradually
BUBBLE HE assessment
Breasts, Uterus, Bladder, Bowels, Lochia, Episiotomy, Homan’s Sign, Emotional Status
Couplet Care
model of caring that emphasizes mother and baby being cared for together, as a pair or “couplet,” during their entire hospital stay by the same nurse
nutrition for breast feeding
o FLUIDS!
o Calories increase by 200-500 calories/day and continuance of prenatals during breast feeding
vaccinations post partum
- Rubella vaccination can be given after delivery, before she goes home
- Varicella vaccination
- Tetanus-diphtheria-acellular pertussis (Tdap)
Rh iso-immunization
Rh immune globulin should be given within 72 hours for R-negative women who deliver an Rh-positive infant
a minimum of how many hours after vaginal birth
48 hours
a minimum of how many hours after cesarean birth
96 hours
Criteria for discharge
o Plan for discharge as soon as the baby is born
o Mom and baby need to be healthy for discharge and need to have education
o Teach nothing in vagina for 6 weeks
Baby needs to see pediatrician…
1-2 days after discharge for jaundice check and weight
Attachment/Bonding
the process by which a parent comes to love and accept a child and a child comes to love and accept the parent
Proximity
proximity and interaction with the infant through which the parent becomes acquainted with the infant and identifies the infant as a member of the family
Mutuality
the infants’ behaviors and characteristics elicit a corresponding set of parental behaviors and characteristics
o Ex: crying, cooing, smiling
Acquaintance
Parents use eye contact, touching, talking and exploring to become acquainted with their infant
Claiming process
identification of the new baby
Assessment of Attachment
-Eye contact
-Appropriate behavior
o Early skin to skin stimulates maternal affection and can help with thermoregulation
-past history of parents
Transition to parenthood is a
DEVELOPMENTAL TRANSITION, not a LIFE CRISIS
post partum blues time period
peak around 5 days and subsides around day 10
post partum depression time period
depression lasts more than 10 days
post partum psychosis time period
goes beyond 10 days, hallucinations about things happening, medical intervention is needed
what leads to post partum blues
Hormone shifts (decrease in estrogen and progesterone and increase in oxytocin and prolactin)
treatment for post partum blues
no medication required
treatment for post partum depression
depression medication
- St. John’s Wort is discouraged because it is not known if it can be harmful to the baby through breastmilk
what screening instrument most commonly used to identify women with postpartum mood disorders
The Edinburgh Postnatal Depression Scale (EPDS)
primary hemorrhage
occurs within 24 hours of giving birth
secondary hemorrhage
occurs after the first 24 hours but within the 6 weeks after delivery
blood amount for vaginal birth is considered hemorrhage
> 500mL
blood amount for cesarean birth is considered hemorrhage
> 1000mL
risk for postpartum hemorrhage
-uterine atony
-lacerations of genital tract
-anemia
-hematoma
-retained placenta
-inversion of uterus
-subinvolution
uterine atony
poorly contracted uterus that does not adequately compress large open vessels at the placental site which can result in hemorrhage
s/s uterine atony
a soft (boggy) uterus is palpated
causes of uterine atony
multiple pregnancies, if they have rapid or prolonged labor, and prolonged use of oxytocin, obesity (large baby), polyhydramnios (large amount of amniotic fluid >1500mL)
Placenta accrete
when placenta is slightly penetrating lining of the uterus (myometrium)
Placenta increate
deeper penetration into the uterus
Placenta percreta
completely into the uterus and can go into other organs too
intervention for placenta increate and percreta
hysterectomy
Anemia must be..
o fixed during pregnancy because it can lead to post-partum hemorrhage.
Hematoma
localized collection of blood in the tissues and can occur internally
retained placenta
Placenta or fragments of the placenta remain in the uterus preventing the uterus from contracting which leads to uterine atony or subinvolution
Inversion of the uterus
turning inside out of uterus
first step for post partum hemorrhage
evaluation of contractility of uterus: DO A FIRM FUNDAL MASSAGE!
second step for post partum hemorrhage
active the protocol (click emergency light, activate medication, call doc, gets nurse help), V/S, IV Fluids (LR), give PITOCIN FIRST AS BOLUS, need to get another IV catheter access because you may need a blood transfusion and it NEEDS ITS OWN LINE!
medication fro second step of post partum hemorrhage
IV Fluids (LR), give PITOCIN FIRST AS BOLUS
third step for post partum hemorrhage
PLACE FOLEY because distended bladder can cause uterus not to contract
fourth step for post partum hemorrhage
give CYTOTEC (Misoprostol) (1000mg given per rectum)
Cytotec (Misoprostol) Administration
rectal (1000mg)
fifth step for post partum hemorrhage
Methergine given IM or PO (never IVPush)
Methergine administration
given IM or PO (never IVPush)
what needs to be checked before methergine is given
§ MUST CHECK BP BEFORE GIVING if BP is elevated cannot give because it causes vasoconstriction and can cause patient to stroke
sixth step for post partum hemorrhage
give Hemabate (Carboprost) given IM (never IVPush)
Hemabate (Carboprost) administration
given IM (never IVPush)
what needs to be checked before Hemabate (Carboprost) is given
MUST MAKE SURE PATIENT IS NOT ASTHMATIC
Two of the most common SE of Hemabate (Carboprost)
N/V/D, so make sure Lomotil or Imodium is ordered to help with diarrhea
seventh step for post partum hemorrhage
BAKRI BALLOON
Bakri Balloon
BAKRI BALLOON which stays in uterus for 24 hours filled with 500 mL of NS, must be removed OVER TIME because you want to observe the bleeding
-Puts pressure on the uterus
Idiopathic thrombocytopenic purpura (ITP)
disorder in which a deficiency of platelets results in abnormal blood clotting, marked by tiny purple bruises (purpura) that form under the skin
Von Willebrand Disease
bleeding disorder caused by a deficiency of von Willebrand factor, a “sticky” protein that lines blood vessels and reacts with platelets to form a plug that leads to clot formation
Disseminated intravascular coagulation
abnormal activation of the proteins involved in blood coagulation, causing small blood clots to form in vessels and cutting off the supply of oxygen to distal tissues
Puerperal sepsis
any infection of genital tract within 28 days after miscarriage, induced abortion, or birth
o Most common infecting agents are numerous streptococcal and anaerobic organisms
Endometritis
inflammation/infection of the inner lining of the uterus
Mastitis
inflammation of the breast as a result of a blocked duct and infection
s/s Mastitis
o localized heat and swelling, pain, elevated temperature
o Intervention: apply heat to site, maintain lactation in breastfeeding mothers, encourage manual expression of breast milk, supportive bra without an underwire
