Unit 4 Flashcards
What and when is the postpartum period?
Period of time between birth and when the reproductive organs return to their normal state. Body system going back to pre-pregnancy state.
Traditionally last 6 weeks.
- Varies from woman to woman
- Depends on delivery, difficulty of delivery, type of delivery
What is involution? When does it happen? Describe the process:
Immediately after delivery:
12 hours:
24 hours:
Day 2:
Day 3:
2 weeks:
6 weeks:
The process by which the uterus goes back down to its pre-pregnancy size and location.
Begins immediately after the placenta delivers (end of 3rd stage of labor).
The uterus begins contracting, we want it to contract immediately after the placenta delivers. Contracting facilitates the uterus going down.
Concerned if the fundus is higher than expected. In general…
- Immediately after delivery: the funds can be palpated a little below the umbilicus. (2 cm)
- 12 hours: may rise up to a cm above the umbilicus (1 cm above umbilicus)
- 24 hours: should be at the umbilicus
Descends at a rate of 1-2 cm per day after 24 hours.
- Day 2: 1 cm below umbilicus
- Day 3: 2 cm below umbilicus
By 2 weeks, the fundus should not be palpable
By 6 weeks, the uterus has completely gone back to its pre-pregnancy location in the pelvis.
What is subinvolution?
What can cause it?
When involution does not happen at the rate that it should. The uterus is not decreasing in size and going down at the rate that it should
Commonly due to pertained placental fragments and infection
Describe contractions in the postpartum period
What makes cramps worse?
What is used to treat it?
Afterpains (after birth cramps)
- Cramping after birth is normal: due to uterus contracting (helps with bleeding)
- After the placenta is delivered, there is a gaping wound, with many blood vessels open. The contractions squeezes all the blood vessels to control bleeding, like a “tourniquet”
- The hormone that mediates this process is oxytocin (naturally released after placenta is delivered)
- A lot of time Pitocin is given after delivery to placenta to help facilitate contractions, this leads to moms complaining of pain
- Periodic relaxation and vigorous contractions are more common in subsequent pregnancies and can cause uncomfortable cramping called afterpains (afterbirth pains)
- What makes cramps worse = breastfeeding, which naturally releases oxytocin (from posterior pituitary)
- With cramping, multips complain of it being worse, this is normal. Has to do with uterine tone, which is not as good after having multiple babies.
- Ibuprofen, Toradol, heat pads given for cramping
Describe the different lochia throughout the postpartum period
What is known to increase lochia?
Lochia: body getting rid of leftover uterus lining
- Lochia rubra (first 3 days): dark to bright red, like a period. Heavier in the first few hours after birth.
- Lochia serosa (4-10 days) Brownish-pinkish color around day 4.
- Lochia alba (10 days up to 4-6 weeks): White-yellow color. Can be done around 10-14 days, can persist up to 6 weeks and that is normal.
- Expect the amount of lochia to taper off as the days go by
- Known to increase lochia flow : “Overdoing it” -> too much activity, ambulation, exercise
- If a mom says she’s just had a lot of heavy bleeding -> if she’s been laying down a while, then stands up and this happens, this is normal (blood pools in the vagina)
Cervix, Vagina, Perineum in the Postpartum period
- Over the first week PP, the cervix begins to firm back up and regains its shape.
- By the end of week 1, the cervix will still be about 1 cm dilated.
- Cervix that has delivered a baby will never look the same as one that has. Vaginal delivery: slit-like opening.
- Vagina: over a few weeks, will begin to decrease in size and gain its tone. Will never go back to exactly how it was prior to birth. Will gradually gain some tone back.
- If a mom is lactating, the prolactin (makes milk levels) are high. This suppresses ovarian function. Estrogen levels will be lower. Estrogen keeps vaginal tissues pink and moist. Moms lactating experience vaginal dryness and pain with sex.
- When assessing mom after delivery, may see: red/inflamed introitus after delivery, laceration, episiotomy repair, hemorrhoids
Pelvic muscles in the Postpartum period
What can help with issues?
- Can get traumatized during the birth process, a lot of times there are not immediate consequences. Again, estrogen keeps all the pelvic tissues healthy.
- When women go through menopause and lose protective effect of estrogen, they experience the consequences of pelvic floor muscle relaxation -> urination issues, uterus or bladder prolapse “going south”
- Kegel exercises -> maintain pelvic muscle tone, reduce likelihood of issues later on
Describe return of ovarian function in the postpartum period
- Prolactin: once placenta delivers, the pregnancy hormones drop drastically (placenta produced hormones).
- This “drop” tells prolactin that it’s time to increase.
- Prolactin levels are going to be influenced by breastfeeding: how long, how often.
- Prolactin suppresses ovarian function, a mom who breastfeeds for a long time may have a while before the ovaries wake up and menses return.
- Return of menses: Later for breastfeeding moms. On average, 6 months postpartum is when breastfeeding moms have their first period.
- Ovulation in non-BF mom can come back as soon as 3-4 weeks after delivery (due to lower prolactin levels).
- BF not a reliable form of contraception
Breast changes in the postpartum period
- Little change 1st 24 hours: for BF and non-BF moms. Most women are able to express some colostrum in the 1st 24 hours (small amounts).
- Over the first few days, breasts become fuller, heavier as milk begins to come in and colostrum transitions to true milk (happens around the 3-5 day mark).
- Most moms experience engorgement, whether BF or non-BF: breasts are tender, warm, firm. So firm the baby could have a hard time getting latched on if BF.
- As long as mom keeps breastfeeding, this is resolved in 24-48 hrs.
- If a mom is not BF and gets engorged (3-5 day), there is 24-48 hours of discomfort, then it subsides when the body realizes she is not BF and stops making milk.
Blood volume and cardiac output changes in the postpartum period
What kind of moms could this affect?
- How did pregnancy affect blood volume? Increased significantly, allows mom to tolerate postpartum bleeding
- A lot of hemodynamic changes in the first couple of days postpartum: fluids shifts.
- The heart is still working harder a couple of days as the body tries to adjust
- How did CO change during pregnancy? Increased.
- Once the placenta is delivered and cord is cut, all the blood has to go back “shift” to maternal circulation. (10% CO to uterus during pregnancy)
- First hour after delivery: Cardiac output is increased even more, above pregnancy levels
- What kind of moms could this affect? Hypertension, cardiac issues. Could make them decompensate, can go into heart failure.
Pulse and blood pressure changes in postpartum period
- Goes up the first hour or two as CO goes up.
- Blood pressure goes up as placental blood goes back to mom (first couple of days), then it should go back to pre-pregnancy levels.
- Orthostatic hypotension is common the first couple of days postpartum due to fluid shifting when mom stands up -> normal and expected.
- Postpartum patient is a fall risk, be with the patient the first few times she gets up.
Labs in the postpartum period
H&H
WBC
Clotting factors
H&H
- After delivery, expect a moderate drop in H/H (losing blood in delivery). - Could be 8-9 after having a 12 before delivery.
- Usually checked next morning after delivery, unless there was a significant amount of blood loss (checked earlier).
- Drops even lower with significant blood loss.
WBC
- WBC increases after delivery, this is normal. Pregnancy/birth is a physiologic stress on the body, so we see a transient elevation: 25,000-30,000 considered normal.
- Never assume stress is the reason: still assess temperature, breath sounds, C/S site for infection.
Clotting factors
- Increase in pregnancy and stay elevated during the postpartum period of 6 weeks
- Postpartum is a risk factor for blood clots, DVT, PE: Assess for signs!!
- Big risk along with obesity, immobility
Urinary changes in the postpartum period
Mom needs to get rid of fluid
- Urine output: Massive diuresis over the first few days.
- Large increase in UO: 3000 mL/day.
- Issues with inability to empty bladder: trauma, swelling; anesthesia
- Bladder distention: due to increased UO and decreased bladder tone.
- Bladder distension can precipitate bleeding -> A distended full bladder prevents the uterus from contracting well.
Gastrointestinal changes in the postpartum period
- Most moms are hungry after delivery (not eating during labor).
- They can be dehydrated
- May take time for bowel function to completely return to normal: because of decreased intake during labor, slowed peristalsis during labor, pain medication
- Expect the first BM in the first 2-3 days
- A lot women are scared of BM due to discomfort, stitches, trauma
Neurological Changes in the postpartum period
- Headaches: Common in postpartum due to different reasons. Could be normal stress headache or exhaustion.
- Could be eclampsia, postdural puncture HA. Carefully evaluate postpartum HA.
- Monitor BP** HA with HTN would be concerning
Musculoskeletal changes in the postpartum period
- Abdominal wall: abdominal muscles regain tone, but not immediately, it happens over time. Women tend to look pregnant after delivery.
- Diastasis recti improves with time
- Pre-pregnancy abdominal tone can affect how they regain tone after delivery
- Hypermobility of the joints go back to normal in postpartum, except for feet (gain a shoe size in pregnancy).
Discharge teaching/timing in the postpartum period
- Discharge teaching: Begins the moment the baby is born. Give little pieces of information in chunks, not all at once.
- Vaginal Birth: ~48 hours Less of a major stressor to the body. Goes home sooner than C/S usually.
- C-section: ~72 hours Major surgery
Couplet care in the postpartum period
- Couplet care (care for mom and baby) all of the care can be in mom’s room
- Infant security: Big deal, babies have an alert band if the baby leaves the area.
- Mom and baby have matching arm bands.
- Do as much care in the room as possible.
- NEVER carry the baby out of the room, it needs to be in the bassinet.
- NEVER leave the baby unattended if mom is not in the room.
Physical Exam/Labs in the postpartum period
Physical Exam: focused. Vital signs, breasts, uterine fundus, lochia, perineum, bladder and bowel function, and lower extremities
Labs:
- Hgb/Hct:** monitor for bleeding
- Urinalysis (UA): especially if mom had a catheter in labor
- Urine culture: especially if mom had a catheter in labor
- Rubella: Titer is usually already done, but the nurse needs to make sure what it is. Done on arrival to hospital if no prenatal care. Give to mom postpartum if she is not immune
- Rh status: usually already done, but the nurse needs to make sure what it is. Done on arrival to hospital if no prenatal care.
Temperature in postpartum period
Intervention
Signs of potential complication?
- 97.2°F-100.4°F: May see transient elevation to 100.4°F due to dehydration from labor for up to 24 hours.
- Low-grade temp, not considered a fever. If within 100.4 and in first 24 hours, we are not concerned
Intervention: Fluids - 100.4°F after 24 h: infection
Heart rate in postpartum period
Signs of potential complications
After initial increase, it should decrease gradually back to normal.
Tachycardia: pain, fever, dehydration, hemorrhage
Blood pressure in postpartum period
Signs of potential complications
- Consistent with BP baseline during pregnancy; transient increase of 5% first few days after birth; can have orthostatic hypotension for 24-48 h
- Hypertension: anxiety, preeclampsia, essential hypertension
- Hypotension: hemorrhage
BUBBLEHE Assessment include…
B = Breast
U = Uterus
B = Bladder
B = Bowel
L = Lochia
E = Episiotomy/Laceration
H = Homan’s/Hemorrhoids
E = Emotional
Still do head to toe, once per shift
Breast Assessment (BUBBLEHE)
Engorgement
What breasts look like in days after delivery
- Engorgement: Check for tenderness, firmness, warmth, enlargement
- Expected whether BF or not
- Happens as a result of milk beginning to come in
- Increase in blood flow to breast
- Increase in lymphatic drainage
- When engorgement happens (3-5 days)
- Different factors determine when: if mom had a baby before, it’s more like 3 days. For C/S moms, it’s more like 5 days
- Once engorged: 24-48 hours of discomfort: breasts get full, hard, tender (pain), warm to the touch
- In non BF mothers, her body will see that she is not breastfeeding, and this will resolve
- In BF moms, when she is engorged, continuously emptying of the breast will help (nursing or pumping) -> engorgement can continue to be a problem if she in not emptying the breast enough
For BF and Non BF moms, this is normal: - Days 1-2: soft
- Days 2-3: filling
- Days 3-5: full, soften with breastfeeding (milk is “in”)
Breast Assessment (BUBBLEHE)
Nipples
Check nipples, especially in BF moms
- Make sure skin is intact: no cracking, bleeding, bruising, blistering, fissures, abrasions
- IF these things happen, it is usually a result of a poor latch
- Can be corrected with teaching
- If not corrected, it is painful and mom could give up on BF
Care of breasts/nipples in BF postpartum mom
- Heat: very stimulating -> facilitates milk production (only for BF moms); warm compresses. A hot shower can be helpful with engorgement
- Supportive bra (breast pads): recommended for both; breasts are so tender and sore that a bra will keep them from moving around too much and help with pain
- Breastfeed or pump: keeping breast empty facilitates comfort
- No soap on nipples: soap is drying and can facilitate issues with skin integrity
- Provide support while in the hospital and suggest support groups for after discharge: increase number of moms breastfeeding
Care of breasts/nipples in non BF moms
- First 72 hours: Supportive bra (also a tight sports bra); breasts are so tender and sore that a bra will keep them from moving around too much and help with pain
- Avoid: Expressing milk, Stimulation , Heat: stimulates milk
Engorgement - Ice packs: comforting (sometimes used in BF AFTER pumping or feeding) decreases swelling
- Cabbage leaves: put inside bra; soothing effects, decreases swelling
- Analgesics: Motrin, percocet
Uterus BUBBLEHE Assessment
Main goal and interventions
Normal:
Signs of potential complications:
- Preventing excessive bleeding: MAIN GOAL
- Common cause: uterine atony - A relaxed, limp, boggy uterus
- Prevention techniques:
Maintain uterine tone: fundal massage
Prevent bladder distention: a full bladder interferes with the uterus’ ability to contract - Normal findings: Firm, midline; first 24 h at level of umbilicus; involutes ≈1 cm (1 fingerbreadth)/day
- Signs of potential complications: Soft, boggy, higher than expected level: uterine atony
Lateral deviation: distended bladder
Lochia BUBBLEHE assessment
Normal:
Signs of Potential Complications:
- Amount: Scant, light, moderate, heavy, excessive
- Scant, light, moderate: ideal
- Expect pattern of bleeding to start out a little heavy right after delivery, but should taper off
- Do NOT want to see excessive bleeding
- Time of last pad change: Assess bleeding in the context of time. How many hours worth of bleeding (how long has pad been on)?
- Color of lochia
- Clots: a few quarter size clots is okay. Do NOT want to see golf ball clots or bigger - sign of uterine atony
- Odor: fleshy odor is normal, foul odor could mean infection
- Check beneath client: Bleeding can go beneath client as they lay in bed
- Weigh the pads: 1 gram = 1 mL of blood
- Remember women can tolerate blood loss pretty well due to the protective mechanisms during pregnancy.
- It takes excessive bleeding to change labs: change in H&H, Blood pressure drops, Increased heart rate, Mom feeling dizzy or faint
- Normal: Amount: scant to moderate, Few clots, Fleshy odor
- Signs of Potential Complications:
Large amount of lochia, large clots: uterine atony, vaginal or cervical laceration
Foul odor: infection
Interventions to maintain uterine tone
Fundal Assessments
- Fundal massage: gold standard for maintaining tone
- Keep other hand above symphysis pubis to prevent uterine prolapse or inversion (flipping in on itself)
- Client position: lying flat is ideal for finding fundus
- Location of Fundus: more concerned if fundus is above where we expect
- Fundal assessments: Done more often right after delivery -> most common time of postpartum hemorrhage
- When palpating the fundus, document…
Location
Midline or deviated
Firm or boggy
Normal, expected finding: firm and midline
Measures that promote involution
- Voiding: make sure mom is voiding regularly (remember bladder distension interferes with uterine contractions)
- Fundal massage: restores uterine tone
- Breastfeeding: naturally releases oxytocin from pituitary gland, causing uterus to contract (moms feel “cramping” after BF)
- Medications: Oxytocin, Methergine, Hemabate
- No results (pt is still bleeding): notify health care provider (After trying previous methods)
Bladder BUBBLEHE assessment
Interventions
Normal:
Signs of Potential Complications:
- Preventing bladder distention: Empty bladder spontaneously ASAP after delivery
- Usually given 6 hours after delivery to void on her own: If not, straight cath. Give another opportunity after 6 hours to pee on her own. If still not peeing on her own, she may get foley
- Reasons why pt may have a hard time peeing: Tissue trauma, swelling , Numb from anesthesia , Stitches “down there”
- To help mom pee: Run water, Peri-bottle/squeeze bottle used to squirt water on perineum while she is sitting on the toilet
- Normal: Able to void spontaneously; no distention; able to empty completely; no dysuria. Diuresis begins ≈12 h after birth; can void 3000 mL/day.
- Signs of Potential Complications: Overdistended bladder possibly causing uterine atony, excessive lochia; Dysuria, frequency, urgency, burning: infection
Bowel Function BUBBLEHE assessment
Interventions
Normal:
Signs of Potential Complications:
Risk for constipation
- Mom is scared
- She didn’t have anything to eat during labor
- Dehydrated
- Pain medications (opioids)
- She hasn’t been moving around a lot (been in bed)
Preventing constipation
- Encourage fluids
- Increase fiber
- Ambulation
- Stool softener/laxatives
Gas pains
- Sometimes an issue postpartum
- More prone to gas pain: C/S moms
- Interventions: ambulation, rocking chair, medications (simethicone), avoid carbonated beverages, avoid drinking through straws
- Normal: Bowel movement by day 2 or 3 after birth
Signs of Potential Complications: No bowel movement by day 3 or 4 -> constipation; diarrhea
