Transistions: normal postpartum

Question 1

when does postpartum start ?

Answer 1

24-48 hrs after birth

72 hrs after C-sec

Question 2

how many stages of labor?

Answer 2

4

Question 3

what does the 1st stage involve?

Answer 3

1. latent phase: when contractions become regular and painful and cervical effacement and dilation commence to 3 cm
   > dont want to give anything for pain, could make contractions stop
2. active phase: labor is well established when contractions becoming more painful, frequent and longer
   > 4-8cm
3. transition phase: contractions take on more expulsive nature, bearing down feeling, mood swings
   > 8-10 cm

Question 4

second stage

Answer 4

commences with full dilation of cervix and ends with delivery of baby

> during: fetal head descends under the pubic arch and gradually thins and stretches the vaginal opening

> contractions occur q 2-3 min?

for primips (nullip)- can last up to 3 hrs - usually push for 60 min

for multip- can be less than 20 min

Question 5

third stage

Answer 5

birth of baby until the placenta and membranes are delivered

> the separation of placenta facilitated by uterine contractions

> once the baby born, the uterus contracts and retracts which causes the placenta to pull away from the wall of the uterus

> usually occurs within 20-30 min. if longer than 30 min, might start to get worried about hemorrage

Question 6

fourth stage

Answer 6

one to 4 hrs after birth, although 2 hrs is most common

> time for psychological adjustment and stabilization for the mother… also includes the baby adjustment to extrauterine life

Question 7

characteristics of postpartum

how long does it last?

Answer 7

> up to 6 weeks after birth

> physical and psychological adjustments to a preperg state

> considered to be retrogressive (getting back to prepreg state) and progressive (C-sec scar/episiotomy)

Question 8

Physiological changes of the uterus

immediately postpartum

Answer 8

> uterus is size of grapefruit, 5 cm below umbilicus and above pubic symph

> the walls clamp and the vessels compress

> 6-12 hrs postpartum—> the uterus is at the umbilicus

> usual descent is 1cm/day. at 10 days, it should be back down

Question 9

what if the uterus is boggy and high?

Answer 9

> causes increase bleeding and clot formation

> uterus is being lazy and can cause increased bleeding

Question 10

what if the uterus is firm and deviated to the side?

Answer 10

> may be a full bladder

> get PT to void IF she is not hemorrhaging

Question 11

what about size/weigh of uterus?

myometrium?

Answer 11

> decrease in weight from 1000 gm to 50gm
reverse hypertrophy. same amount to cells. just shrink

> myo- lining of uterus. takes about 3 weeks to heal and the placenta site takes about 6-7 weeks to heal

Question 12

how do you check the fundus?

Answer 12

one hand at pubis and other at top of fundus.

use only one hand if she had a C-sec

Question 13

what factors affect involution

Answer 13

(causing no contraction…)

1. prolonged labor
2. GA
3. excessive analgesia
4. difficult birth
5. grand multip- 5 or more. poor uterus muscles
6. overdistension of the uterus- too much amniotic fluid (polyhydramnious), big baby, twins
7. full bladder
8. retention of products of conception
9. infection

Question 14

When mom gets up out of bed she feels blood gush and run down her leg. What do you do?

Answer 14

> ease mom back to bed and assess how much blood loss, clotting, pad? is it coming from a tear?
assess fundus
do VS
do more frequent assessments
massage the uterus
have her empty bladder q2h. she would lose sensation after birth and so getting her to pee would start to dierese her
get her brest feeding. hormones are released from feeding which will help contraction of the uterus

Question 15

changes to the Cervix, vagina and perimeum

Answer 15

cx and vag-
>bruised and poss lacerations
> decreased vag tone
> dysparunia (painful intercourse) - teach the use of water sol gel

perineum-
> intact? tear or episiotomy?
> assess for REEDA ( redness, edema, ecchymosis, discharge and approximation), pain
> also assess for hamorrhage

Question 16

Nursing interventions for perineum

Answer 16

> assess for pain q shift or more
assess knowledge- how to care for site

Teach:
> application of ice pack or tea bag pads (titanic acid draws out the swelling, inflam, bacteria
> Peri bottle usage- little soap and water. use after voiding
> inspect and wipe clean to dirty
> kegals
> sitz bath- for up to 20min a few times per day

Question 17

reproductive health

Answer 17

return to mensuration varies

non-breast feeding = 7-12 weeks

breast feeding can be as early as 12 weeks and as delayed as 3

Question 18

return of ovulation

Answer 18

non-breast feeding 70-75 days

breast feeding 6 months

Question 19

teaching sexual activities

Answer 19

> after lochia serosa
when there is decreased pain
alternative positions
use of lubricant

> talk about contraception

Question 20

Changes in the GI system

Answer 20

Delay in BM
> there is decreased eating during labor
> often BM in L and D d/t pushing
> fear of BM d/t pain from episiotomy

Nursing:
> give stool softeners
> diet high in roughage and + fluids (for BM and breast feeding)
> hemorrhoid care

Question 21

change in urinary system

Answer 21

caused by:
> increased capacity
> swelling
> bruising and pain
> decreased sensation

Nursing:
> assess amount, frequency and characteristics

Teach:
> need to empty q2h
> S and S of bladder infection

Question 22

changes in VS

Answer 22

always go back to see what her normal was.

Temp:
> 1st 24 hrs can be up to 38.0 C d/t over exertion and dehydration
> if elevated temp after 24 hrs, infection? premature rupture of membranes?
> if elevated temp 3-4 days, could be d/t lactogensis (milk coming in). only seen if the mom had a C-sec

BP:
> transient increase to normal within a few days
> exceptions. PIH (preg inducted HTN) and PPH (post-part hemorrhage

Pulse:
> bradycardia for 6-10 days = Normal
> tachycardia associated with blood loss, infection, fear and pain

Question 23

blood changes

Answer 23

Leukocytosis - esp in long labors
> increased defense against infection, increased healing process
> 25,000 - 30,000 (usual 4,500 - 11,000)
> will return tp normal by the end of the first week

Hgb and Hct
> assess after day 2, normal or better in 2-6 weeks
> Hgb below 120 = anemic
> best indicator to assess Hgb is after she has diuresed
> best assessed after day 2 - due to hemodilution

Question 24

other blood changes

Answer 24

Platelets:
> fall due to placenta separation
> increased by the 3-4 day

Fibrinolytic levels:
> normal for first few hrs but are at risk for thromboembolism in first 6 weeks d/t increase diameter of veins.
> talk to mom about exercising
> rub the legs all the way down to feel for any painful and hot spots
> also assess CWMS

Question 25

factors associated with risk of thromboembolic disease

Answer 25

> pelvic or abd surgery - C-sec or abd surg is at higher risk
> hx/fam hx of disease
> obesity (BMI >30)
> age >35
> operative delivery - forceps
> varicose veins
> prolonged immobility 
> multiparity ***
> active infection or inflammation

Question 26

other blood tests to consider postpartum:

Answer 26

blood group and type:
> mom Rh- and baby Rh+. if mom is -, must check baby

Rubella titre:
> if mom had titre < 10 yr or if she is considered non-immune, mom will need MMR vaccine. give to mom bfr she goes home. it would protect the next baby. not this one.

Question 27

altered comfort/pain r/t

Answer 27

> peritoneal pain d/t tear/episiotomy…

after pains d/t decreased tone of uterus and alternating contractions and relaxing of the uterus.
> increase in oxytocin admin
> increase breast feeding
> increases with multips or with distended uterus (large baby, twins, hydramnious)
> severe up to 2-3 days

Nursing interventions:
> education
> analgesics –> often given bfr breast feeding. tylenol/ibuprofin
> change positions. on side and give warm blanket

Question 28

Cesarean birth post-op care:

Answer 28

> most women would have had a spinal or epidural anesthesia for C-sec which restricts sensation and motor function

> policy dictates frequency of assessment. resp q…?

> women will have a longer recovery time, breast feeding can be more challenging d/t painful incision area.
Teach different positions. on side, pillow…

> may feel angry/disappointed that they failed. let them ask questions, express feeling and seek clarity

> reinforce that vag birth is poss after C/S

> teach about wound infection: redness, swelling, discharge, increased pain and when to go to the doctors

Question 29

psychosocial dimensinos

Rubin Theory

Answer 29

1) taking in phase
> first 1-2 days.
> passive, somewhat dependent and preoccupied with her own needs. Needs to talk about L and D
> food and sleep and major focus

2) taking hold phase
> around 2-3 days
> becomes concerned about care of baby and is ready to learn.
> becomes more independent

3) letting go phase
> defines new role and gives up old role
> rqrs grief work and readjust of relationships

Question 30

Posr partum blues

how do these women present?

Answer 30

> transient. non-problematic. experienced by 50-80%

> appears within first few days and resolves within 10-14 days

\: 
>mood swings
> anger
> teary
> anorexia
> diff sleeping
> letting down feeling

Cause:
> changing hormonal and psychological adjustment, insecurity, unsupported environment, fatigue, discomfort and overstimulation

Nursing interventions:
> assess
> ask them the seek assistance and do this when dad is in the room
> let them know what to look for so it doesnt turn into PPD
> mom might not realize. other ppl will notice bfr her

Question 31

PPD

Answer 31

> 10-15% of women experience within the first year of birth
more serious than the blues with intense mood swings and pervasive sadness
many women go to great lengths to conceal their ppd. family notice. include family in teaching so they can recognize the S/S and can know what to watch for

Question 32

postpartum psychosis

Answer 32

> rare with 0.1 - 0.2 % of women affected

> includes auditory and visual hallucinations, paranoia, delirium and impulsive thoughts and actions

Question 33

becoming a father

Answer 33

> some men feel excluded, like sitting on the sidelines

> include dad and give them jobs

Question 34

parent education

newborn care:

Answer 34

> importance of skin to skin. keeping baby warm. one more layer than adult
feeding q3 hr
infant crying. let baby cry for 5 min. avoid shaken baby syndrome
diaper changes: 6-10 wet/ day
poop? other slide
sleep: need to wake baby up to feed. no bumper pads. no tight swaddle. no sleeping with baby

> cord: keep dry and check for redness
bathing
tummy time: to help with neck muscles and shape of head
consoling techniques: soother
jaundice
car seat safety: need to bring in to be checked
weight loss/gain
immunizations
follow-up doc apt- babies best chance book

Question 35

poop

Answer 35

meconium: thick, tarry, dark green
transitional: thin brown/green
breastfed: yellow/gold, soft/mushy

formula fed: pale yellow, pale/pasty

Question 36

maternal care

Answer 36

> newborn feeding: breast, nipple care, engorgement, expressing, rest/activity, maintaining adequate hydration
PP blues and depression
smoke free environment- wash hands/smoke jacket
self-care: flow, what to expect, peri bottle, nutrition, pain management, contraception/sex, incision care, when to call doc
increased pain, increasing bleeding
aware of public health nurse contact
alteration/ change or lochia
notice of increased swelling (thrombophlebitis)
breast infection signs
sexual activity - lochia stopped (3 weeks up to 6 weeks). might experience vag dryness
bowel elimination