W8 - Postpartum Care Flashcards
(164 cards)
1
Q
When is the postpartum period?
A
- 6 weeks after birth
- Interval between birth and the return of the reproductive organs to normal, nonpregnant state
2
Q
Pernieal Lacerations
A
Perineal lacerations are tears in the skin and underlying tissues of the perineum that occur during vaginal birth.
3
Q
How are perineal lacerations classified?
A
They are classified by degree based on
- the depth
- structures involved
ranging from
- superficial skin tears
- to those extending through the anal sphincter and rectal mucosa.
4
Q
Perineal Lacerations: First degree
A
Laceration extends through the skin and structures SUPERFICIAL to the muscles
- Perineal skin only.
- Superficial
- Do not involve muscle
- Vaginal skin around the opening
- Usually do not require suturing and will heal on their own without intervention
5
Q
Perineal Lacerations: Second Degree
A
Laceration extends through muscles of the perineal body
No involvement of the anus or the anal sphincter.
Often do require suturing to repair the area
6
Q
Perineal Lacerations: Third Degree
A
Laceration continues THROUGH the anal sphincter muscle
- Requires close followup and monitoring
7
Q
Perineal Lacerations: Fourth Degree
A
Laceration also involves the anterior rectal wall
- Most severe
8
Q
Best way to assess the perineum in the postpartum period
A
- Good source of light
- Examine the perineum in the lithotomy position
or
have the patient turn to their side and lift up the buttocks.
9
Q
Three Major Factors that Increase Risk for Perineal Lacerations
A
- Size of passenger
- Size of passageway
- Presentation
10
Q
Perineal Laceration Risk Factors: Size of Passenger
A
- Larger passenger (macrosomia)
- Shoulder dystocia
- Use of forceps/suctioning required to remove passenger
11
Q
Perineal Laceration Risk: Passageway
A
- Narrower passageway = higher risk
- Primigravida patients at much higher risk
12
Q
Perineal Laceration Risk: Presentation
A
- OP presentation, lacerations can extend toward the urethra
13
Q
What are 3/4th degree perineal lacerations referred to as?
A
Obstetric Anal Sphincter Injury (OASI)
14
Q
Two Other Perineal Laceration Risk Factors
A
- Psychological
- Stress can impact the ability of the perineal muscles to relax - Pushing
- Prolonged or rapid pushing can increase risk of trauma
15
Q
What are common signs of normal healing after perineal repair?
A
Well-approximated sutures, some edema, and possible itching or mild discomfort.
16
Q
What postpartum symptoms require further assessment of the perineum?
A
Abnormal discharge, redness, severe or worsening pain, or signs of infection.
17
Q
What methods are used to manage perineal pain and swelling in the first 24h postpartum?
A
Ice Packs
NSAIDs
18
Q
How long does perineal healing typically take?
A
Superficial healing: 2-3 weeks
Deep tissue healing: up to 6 months
19
Q
Name key risk factors for 3rd and 4th degree perineal tears.
A
- Macrosomia
- shoulder dystocia
- use of forceps/vacuum
- OP presentation
- primigravida
- narrow pelvis
- prolonged or precipitous pushing
- maternal stress.
20
Q
What are some key elements of health teaching for patients with perineal tears?
A
Perineal care, pain management, promoting bowel regularity (fiber, fluids, ambulation), and proper hand hygiene when changing peri pads.
21
Q
T/F: Tears are often smaller than an episiotomy?
A
True
In terms of risk of injury, it is preferred for a patient to naturally tear than to have an episiotomy.
They are not typically done in Canada but are used emergently to increase the area and expedite the birth.
Some countries have high rates where it is done routinely, in canada it is done about 17% of the time.
22
Q
T/F: Routine episiotomy is recommended in Canada?
A
False
23
Q
Episiotomy: Definition and incidence
A
Incision in the perineum to enlarge the vaginal outlet
17% incidence in Canada
24
Q
Episiotomy: Two types of incisions
A
- Midline
- Mediolateral
25
Episiotomy: Midline
(Also called median)
- Most common
- Surgical cut along the midline.
- Minimizes blood loss and is less painful during post partum recovery
**Runs the risk of further laceration and tearing as the patient pushes. Can lead to 3/4 degree tears.**
26
Midline Episiotomy: Consideration
**Increased risk of THIRD and FOURTH degree laceration**
27
Episiotomy: Mediolateral
**Prevents 4th degree lacerations**
but
- Greater blood loss
- More difficult/painful repair
28
What are vaginal lacerations and when do they occur?
Vaginal lacerations often occur in conjunction with perineal tears and can extend up the lateral vaginal walls or high into the vaginal vault.
29
What causes cervical lacerations during childbirth?
Cervical lacerations may occur when the cervix retracts over the advancing fetal head, often due to pushing or delivery before full cervical dilation.
30
What is a possible long-term consequence of cervical lacerations?
They may lead to cervical insufficiency, increasing the risk of premature cervical dilation in future pregnancies.
31
What factors increase the risk of vaginal or cervical lacerations?
- Premature contractions
- cervical edema
- rapid labor progression
Can increase the risk of tears extending toward the vaginal vault or cervix.
32
What is a normal postpartum blood pressure finding?
BP should be consistent
Orthostatic hypotension is common for up to 48 hours due to decreased pelvic pressure.
33
What are potential complications of abnormal postpartum BP?
Hypertension (e.g. preeclampsia, anxiety)
or
Hypotension (e.g. late-stage PPH from >20% blood loss).
34
What is a normal postpartum heart rate?
60–100 bpm
May be slightly elevated in the first hour after birth but should return to baseline.
35
What are potential causes of postpartum tachycardia?
Pain
fever
dehydration
infection
postpartum hemorrhage (PPH)
36
What is the normal postpartum respiratory rate?
16–24 breaths per minute
37
What are potential complications of abnormal RR postpartum?
Tachypnea from anxiety
pain
infection
embolism
bradypnea from narcotics or magnesium sulfate.
38
What is a normal postpartum temperature?
36.2–38°C
May be elevated in the first 24 hours due to dehydration.
39
What does a febrile postpartum temperature indicate?
Temperature >38°C may indicate infection and requires further evaluation.
40
What level of pain is expected postpartum?
Mild pain from uterine cramping is expected
severe pain may indicate underlying complications.
41
One rare but serious cause of postpartum tachypnea
Embolism from **amniotic fluid** that can enter the maternal blood stream
Presenting with:
- sudden acute dyspnea
- Tachypnea
42
Normal Volumes of Blood Loss During Delivery
Vaginal: up to 500 ml
C-section: up to 1 L
**Greater than this in either case is considered PPH**
43
What are the key postpartum changes in blood components, and why do they matter clinically?
Hematocrit drops for 3–4 days post-delivery and normalizes by 8 weeks if blood loss was within normal range
WBCs and ESR rise postpartum, which can obscure signs of infection
Clotting factors and fibrinogen remain elevated, creating a high risk for thromboembolism
Encourage early ambulation; some patients may require anticoagulants due to this hypercoagulable state
44
What happens to hematocrit levels postpartum with normal blood loss?
Hematocrit drops for 3–4 days after delivery and returns to prepregnancy levels by 8 weeks if blood loss was within the normal range
(≤500 mL for vaginal, ≤1 L for C-section).
45
Why is elevated WBC not always a sign of infection postpartum?
Leukocytosis is common postpartum and peaks in the third trimester due to the inflammatory response of labour; it may obscure signs of acute infection.
46
Why might ESR be misleading as a diagnostic tool postpartum?
ESR may be elevated due to the systemic inflammatory response of delivery and not necessarily due to infection, so it must be interpreted within clinical context.
47
hy is there a high risk for thromboembolism postpartum?
Clotting factors and fibrinogen remain elevated, maintaining the hypercoagulable state of pregnancy; decreased mobility further increases risk for DVT and PE.
48
**IMPORTANT** When is LMWH given postpartum?
Given if risk factors are present:
- Previous embolism
- Higher BMI
- Lost excessive amount of blood during birth
- Preeclampsia
- Required an emergency C-section
- Smoking
49
What hormonal changes occur after delivery of the placenta?
Rapid drop in:
estrogen
progesterone
cortisol
hCG
hPL
placental enzyme insulinase.
50
What happens to estrogen levels after birth?
Estrogen DROPS
Reaches its lowest point about 1 week postpartum.
51
What happens to insulinase levels postpartum and why is this important?
Insulinase DECREASES after delivery
reducing insulin resistance and often resolving gestational diabetes
**May cause hypoglycemia risk.**
52
What hormones increase after birth to support lactation?
Prolactin (stimulates milk production)
oxytocin (stimulates milk letdown and uterine contraction)
53
When does menstruation typically return postpartum?
Non-lactating: ~12 weeks postpartum
Lactating: ~6 months postpartum (due to high prolactin suppressing ovulation)
54
When is a postpartum client typically transferred to a postpartum room?
After an initial 1–2 hour recovery period **if stable**.
55
What is an LBRP and how does it differ from standard care?
Labour-Birth-Recovery-Postpartum room
client remains in the same room throughout all stages instead of transferring.
56
What are key focuses in the postpartum recovery area?
Promote rest and recovery
Support family attachment
Establish infant feeding
Emphasize health teaching
57
Obstetrical Patient Transfer Report
Be able to read/interpret these
58
What is significant? You receive the following report:
- Eve Sherrif, 34-year-old female. Supportive partner present
- G2P2
- ABO/Rh: A Negative
- Rubella: Non-immune
- Uncomplicated pregnancy
- Presented to L&D with SROM at 39 weeks, membranes ruptured 4 hrs prior, no contractions
- Admitted for oxytocin induction
- GBS positive, received PenG
- Intrapartum fever (COVID screening negative)
- Epidural given, motor block resolved
- Vaginal delivery with 2nd-degree tear, repaired
- EBL: 550 mL
- Vitals: BP 118/70, HR 76, RR 18, Temp 36.8
- Fundus firm @ umbilicus, lochia rubra moderate
- PIV infusing R/L with 20 units oxytocin at 125 mL/hr
- Has not voided; last I&O was 500 mL of urine (1 hr ago)
- Tylenol and ibuprofen given 30 min ago
- Misoprostol given 1 hour ago
The estimated blood loss of 550 mL meets the threshold for postpartum hemorrhage in a vaginal delivery, which is any loss greater than 500 mL.
The fundus is firm and located at the umbilicus, which is an expected and reassuring finding.
The patient has not voided since delivery. This is important because bladder distension can interfere with uterine contraction and increase the risk of uterine atony and further bleeding.
Group B Strep positive status combined with an intrapartum fever increases the risk of neonatal infection. Both mother and baby require continued monitoring.
The patient is Rh negative. If the baby is Rh positive, WinRho (Rh immune globulin) will need to be administered within 72 hours postpartum.
The patient is non-immune to rubella. MMR vaccination should be offered in the postpartum period, as it is safe to administer now and will provide protective maternal antibodies if breastfeeding.
Prolonged rupture of membranes along with oxytocin induction increases the risk of infection.
Misoprostol and oxytocin were both given, indicating active management of the third stage of labor and likely in response to elevated blood loss.
The second-degree tear is a common injury during vaginal birth and has been repaired. It should be monitored for proper healing.
Pain is being managed with Tylenol and ibuprofen. Continue to assess for effectiveness and any signs of inadequate pain control or complications.
59
What does the acronym BUBBLEEE stand for in postpartum physical assessment?
B – Breast (firmness) and nipples
U – Uterine fundus (location and tone)
B – Bladder function (amount, frequency, dysfunction)
B – Bowel (passing gas or bowel movement)
L – Lochia (amount and colour)
L – Legs (edema, DVT risk)
E – Episiotomy/laceration/caesarean incision (healing, approximation)
E – Emotional status (mood, fatigue, bonding)
60
Postpartum Breast Exam: Normal Findings
Day 1-2: Breasts are soft
Days 2–3: Breasts begin filling
Day 3-5: Breasts are full.
- Firm before feeding, soften after feeding.
Nipples should be intact with no soreness or damage.
61
Postpartum Breast Exam: Potential Complications
1. Mastitis
- Infection of the milk ducts
- Typically occurs when the ducts have not adequately emptied and bacterial growth develops
2. Engorgement
- Firmness, heat, pain
3. Trauma from latching
- Redness
- Bruising
- Cracks
- Fissures
- Abrasions
- Blisters
62
Is breastfeeding contraindicated with mastitis?
No
63
Colostrum to Mature Milk: Timeline
3 Days: Mostly colostrum
- Golden colour
5 Days: Traditional breastmilk
- A combination of colostrum AND pure mlk
6 Days: Progressively more milk
25 Days: Mostly milk
64
Why is colostrum gold in colour?
High concentration of maternal antibodies
65
How does milk production regulation shift after birth?
Initially: milk production is **hormonally driven** (endocrine).
It later transitions to an **autocrine** system (Cell self-signalling due to mechanical stimulation),
Supply depends on how often and effectively the breasts are emptied. If milk is not regularly removed, production will cease.
66
Milk/Colostrum Production: How does this differ for a non-breastfeeding patient?
The endocrine system drives the initial production of colostrum.
Clients may experience breast tenderness and engorgement in the first few days postpartum.
This discomfort typically results from temporary venous and lymphatic congestion, not milk accumulation.
Symptoms generally resolve within 24 to 36 hours.
As the hormonal environment shifts to autocrine control, the lack of stimulation leads to involution of milk-producing cells and cessation of milk production.
67
T/F: To relieve engorgement, clients should be encouraged to hand express.
False. Hand expression stimulates milk production and is not recommended for non-lactating clients.
68
T/F: Fresh cabbage leaves can be applied to the breasts.
True. Cabbage leaves can help relieve breast engorgement discomfort.
69
T/F: Mild analgesia such as Tylenol and Ibuprofen are effective treatment options for engorgement in a non-breastfeeding patient.
True. These are appropriate for managing postpartum breast pain or discomfort.
70
T/F: Non-breastfeeding patients with engorgement should be encouraged to wear a well-fitted sports bra.
True. Supportive bras help reduce breast discomfort during engorgement.
71
Mastitis
- Definition
Def: Infection of the milk ducts due to an accumulation of milk that has not been excreted
72
Mastitis: Signs and Symptoms
Breast Pain
Swelling
Localized redness
Warmth on palpation
Tender on palpation
May be febrile
May be lethargic
73
When is mastitis most common?
**First six months**
Most common in the first few months after breastfeeding as the milk supply is being established.
or
If pt suddenly stops breastfeeding without naturally reducing output.
74
The uterus at full term weighs approximately ___ times its pregnancy weight
A) 5
B) 11
C) 25
B) 11
At term, it weighs 11 times its pre-pregnancy weight.
During pregnancy: 60-80 grams
At term: 1000 grams
75
What role does uterine contraction play postpartum, and how is oxytocin involved?
Hemostasis after birth is achieved by compression of the intramyometrial blood vessels, not by clot formation.
Oxytocin, released from the posterior pituitary gland (and sometimes given exogenously), stimulates strong and coordinated uterine contractions.
A firm, contracted uterus compresses the blood vessels and helps prevent postpartum hemorrhage
76
How does breastfeeding impact uterine contractions after birth?
Breastfeeding and skin-to-skin contact stimulate natural oxytocin release, which enhances uterine contractions and reduces the risk of postpartum hemorrhage.
77
How can you assess if the uterus is contracting properly after delivery?
A properly contracted uterus feels firm and well-defined, like a taut balloon.
A soft or “boggy” uterus may indicate inadequate contraction and increased bleeding risk.
78
Which of the following clients is most likely to experience increased uterine afterpains?
1. Primigravida that delivered at 38 weeks to a singleton
2. Primigravida that delivered multiples prematurely at 27 weeks
3. Multigravida that delivered at 40 weeks with polyhydramnios and a LGA infant
4. Multigravida that had a precipitous delivery
3. Multigravida that delivered at 40 weeks with polyhydramnios and a LGA infant
This client has multiple risk factors for increased uterine afterpains:
- higher gravida status (making it harder for the uterus to contract)
- uterine overdistention (from both polyhydramnios and a large baby)
Which contribute to more frequent and intense involution cramps.
79
What is uterine involution?
Uterine involution is the return of the uterus to its nonpregnant state.
80
When does uterine involution begin?
The process begins with the expulsion of the placenta.
A rapid decrease in estrogen and progesterone causes autolysis of the hypertrophied tissue in the uterus.
81
How do you assess the uterine fundus postpartum?
Place the lower hand just above the symphysis pubis to support and anchor the uterus.
Use the upper hand to gently cup and palpate the fundus to assess its position and firmness.
Note the fundus’s location relative to the umbilicus and whether it feels firm or boggy.
82
Uterine Involution: Immediately after birth, the uterus should be...
- Midline and FIRM
- The fundus should be at the umbilicus or 2 cm below it
83
Uterine involution: Potential cause of a deviated uterus?
FULL BLADDER
Have pt void before assessment
84
Uterine involution: What may happen after 12 hours and why?
After 12 hours, the uterus may rise slightly ABOVE the level of the umbilicus
Due to a temporary increase in uterine muscle tone as part of the involution process.
This elevation is **normal** and reflects the uterus beginning to contract and return to its pre-pregnancy state.
85
Uterine Involution: 24 hours after birth, the size of the uterus is...
Equal to the same size as 20 weeks gestation
86
Uterine Involution: Rate of Involution after the first 24 hours
Continues to descend 1-2 cm every 24 hours
87
Involution: Location of the uterus by day 6
Halfway between UMBILICUS and SYMPHYSIS PUBIS
88
At how many weeks postpartum should the uterus no longer be palpable abdominally?
1. 1 week
2. 2 weeks
3. 4 weeks
4. 6 weeks
2 weeks
By 2 weeks postpartum, the uterus should have descended into the true pelvis and no longer be palpable through the abdominal wall.
89
Subinvolution
- Definition
Failure of the uterus to return to nonpregnant state
90
Common Causes of Subinvolution
Retained placenta
Infection
91
Subinvolution: How can you tell if the placenta has been entirely passed?
- Observing what has come out and ensuring that all pieces are present and it is intact.
No missing parts of the membrane are visibly evident.
More reliable: ULTRASOUND
92
S/S of subinvolution
Persistent bleeding with large clots
Presence of fibrous tissue
Delayed uterine descent
The bleeding will continue if there is retained placenta. There will be large clots with fibrous tissue that can't be separated, which (might) be an indication of retained placenta
93
Subinvolution: Infection
Endometritis
94
Uterine Atony
Failure of the uterine muscle to contract.
It presents as a boggy uterus on palpation and is the leading cause of postpartum hemorrhage.
95
What is the leading cause of PPH?
Uterine Atony
96
What percentage of PPH is caused by uterine atony?
Approx 80%
97
Uterine Atony: Risk Factors
high gravidity
polyhydramnios
large for gestational age infants
retained placental fragments.
98
What medications can increase the risk of uterine atony?
Magnesium sulfate (used in preeclampsia management) can relax the uterus and increase the risk of uterine atony and postpartum hemorrhage.
99
Lochia
Lochia is the vaginal discharge that occurs after childbirth as the uterus sheds its lining.
It consists of blood, mucus, and uterine tissue
100
Stages of Lochia
Normal stages:
Days 1–3: Rubra (dark red)
Days 4–10: Serosa (brownish red or soft pink)
After day 10: Alba (yellowish white)
101
Lochia Rubra
DAY 1 - 3
DARK RED
102
Lochia Serosa
DAY 4 - 10
BROWNISH RED OR SOFT PINK
103
Lochia Alba
AFTER DAY 10
YELLOWISH WHITE
104
How long does lochia typically last?
Typically lasts 4-8 weeks postpartum
105
Lochia: What is a concerning finding?
**Going BACKWARDS in the stages of lochia**
Eg pt 3 weeks postpartum, has locha alba, then suddenly develops lochia serosa
106
T/F: The amount of lochia is usually less after caesarean birth
True
Often in the OR the OB will do suctioning and remove a lot of the discharge that would otherwise remain in the uterus.
107
T/F: The flow of lochia often increases with ambulation
True
Lochia can pool in the vagina while the patient is supine, and then release with position changes or ambulation.
This is **normal** unless it’s a sudden, heavy gush independent of movement.
108
A perineal pad saturated in how many minutes or less is of immediate concern?
15 minutes
Saturating a peripad in 15 minutes or less suggests excessive postpartum bleeding and warrants immediate assessment for PPH.
109
Perineal Pad Saturation: 5 cm
Scant
110
Perineal Pad Saturation: 10 cm
Light
111
Perineal Pad Saturation: 15 cm
Moderate
112
Perineal Pad Saturation: >15 cm
Large
113
Perineal Pad Saturation: Very Important Consideration
How LONG has the pad been there?
Eg Large in 15 minutes is very concerning. Large in 4 hours is less concerning
114
Lochia: Where is an important location to assess and why?
Under the patient's buttocks.
Blood can pool behind or under the patient, making bleeding appear minimal when it may actually be excessive.
Turning the patient and checking beneath them helps detect hidden blood loss.
115
Case Study: Eve
What is concerning here?
You are given the following report:
Pt 4 weeks pp following vaginal delivery with PROM at 39 GA
GBS positive, intrapartum fever, antibiotics administered
Seeking medical attention related to
1. Abdominal tenderness
2. Fever and chills
V/S
- BP 110/62
- HR 92
- RR 20
- TEMP 38.2C
- PAIN 6/10 w palpation to abdomen
Note: Malodorous lochia rubra serosa
At 4 weeks postpartum, lochia should be alba, not rubra-serosa.
Foul-smelling lochia suggests infection.
Uterine tenderness and pain on palpation are red flags.
Temp of 38.2°C is febrile.
History of PROM and GBS positive status adds infectious risk.
Intrapartum fever increases likelihood of lingering infection.
HR 92 and BP 110/62 could reflect early signs of systemic response.
116
Case Study: Eve – What could be going on?
Endometritis is likely, potentially linked to chorioamnionitis that developed intrapartum.
Retained placental fragments may be present, leading to prolonged lochia and infection.
GBS colonization may have led to ascending infection, particularly given PROM.
117
Case Study: Eve – What diagnostics would be appropriate?
Transvaginal ultrasound to assess for retained placental tissue.
CBC to evaluate WBC count and markers of systemic infection.
Blood cultures to rule out bacteremia or sepsis.
118
Case Study: Eve
Potential Treatments
If retained placenta is suspected, manual removal if the cervix is open.
Dilation and evacuation (D&E) if the cervix is closed.
Broad-spectrum IV antibiotics for presumed endometritis (e.g., clindamycin + gentamicin).
Antipyretics for fever and pain management.
Monitor vital signs and bleeding closely.
Fluid resuscitation if signs of systemic infection or hemodynamic compromise emerge.
Admission for observation if febrile, hemodynamically unstable, or requiring IV meds.
119
Caesarean Incision Inspection
REEDA
Redness
Edema
Ecchymosis (discoloration)
Drainage
Approximation
120
C-Section: Important Consideration
Activity restriction
- No heavy lifting, nothing heavier than the weight of the baby for the first SIX WEEKS
121
Postpartum Health Education Topics
- Frequent hand hygiene before/after peri care
- Frequent changing of peri pads
- Ice packs (first 24 hours)
- Use WARM water in peri bottle with each void
- Gently pat dry from urethra to anus
- No use of tampons
- Kegel exercises
- Sitz bath
- Topical applications
122
What are Kegel exercises and how should they be performed postpartum?
Kegel exercises are pelvic muscle exercises designed to strengthen and support the pelvic floor.
The patient should be instructed to contract the muscles as if trying to stop urine midstream.
Each contraction should be held for at least **10 seconds**
Followed by 10 seconds of rest.
For best results, perform the exercises for 15 minutes twice daily.
123
How often should kegels be performed postpartum?
15 minutes BID
124
What happens to kidney function postpartum?
Kidney function initially decreases but returns to normal by 1 month postpartum.
125
What immediate changes occur to the urinary system post partum?
**POSTPARTUM DIURESIS**
Within 12 hours after birth, patients begin to lose excess fluid through diuresis + sweating.
126
Why does postpartum diuresis occur?
**DECREASE IN ESTROGEN + PROGESTERONE AFTER PASSING PLACENTA**
Normally, estrogen promotes sodium and water retention by upregulating RAAS and increasing ADH sensitivity.
After delivery, the rapid drop in estrogen leads to:
- Downregulation of RAAS activity → decreased aldosterone → less sodium reabsorption → more sodium and water excretion
- Reduced ADH sensitivity → less water reabsorption in the kidneys → increased urine output
This is compounded by the simultaneous DECREASE in progesterone which would otherwise constrict the ureters
127
When does postpartum diuresis typically resolve?
Pregnancy-induced hypotonia and ureteral dilation resolve by 6 weeks postpartum.
128
What symptoms commonly accompany postpartum diuresis?
Profuse sweating and high urine output for 2–3 days postpartum.
129
Why might postpartum clients have decreased awareness of bladder fullness?
Trauma
increased bladder capacity
effects of epidural/spinal anesthesia
130
What else might cause difficulty with urination postpartum?
Perineal lacerations or episiotomy may cause tenderness during voiding.
131
Serious Complication of Postpartum Diuresis
Distended Bladder
132
How can bladder overdistension affect postpartum recovery (immediately)
Immediately postpartum, an overdistended bladder can displace the uterus upward and laterally
**preventing it from contracting firmly**
This increases the risk of excessive bleeding.
133
How can bladder overdistension affect postpartum recovery (Long Term)
Longer term, bladder overdistension may delay restoration of bladder tone and **increases the risk of urinary tract infection**
134
**IMPORTANT**
How often should a patient be voiding after birth?
q4h
135
**IMPORTANT**
What should the volume of urinary voids be for the first 8 hours after birth?
At least 200 ml
May be larger (up to 1000 ml if they didn't feel the urge to void)
136
Frequency of bowel elimination in postpartum period
May not have a bowel movement for 2-3 days postpartum
**Tenderness rt hemorrhoids, episiotomy, laceration**
137
Bowel Management Postpartum
Fluids
Fibre
Ambulation as tolerated
**Stool softeners**
138
What increases the risk of postpartum bowel incontinence?
Instrumental vaginal birth (forceps, suctioning)
4th degree lacerations
139
Patient self-management for pain postpartum
Acetaminophen 325 - 650 mg q4h prn
Ibuprofen 200-400 mg q4-6h prn
140
Who should receive the rubella vaccine postpartum?
Patients who are:
- non-immune to rubella
- indicated by a titer **less than 1:8 **
- enzyme immunoassay level **below 0.8**
141
What kind of vaccine is the rubella vaccine and how is it administered postpartum?
Live attenuated
subq
142
Is the rubella vaccine safe during breastfeeding?
Yes, the rubella vaccine is compatible with breastfeeding.
143
What important precaution must be taken after receiving the rubella vaccine postpartum?
**Live vaccine = teratogen**
Conception should be avoided for at least one month after vaccination due to teratogenic risk.
144
What is the purpose of administering Rh immune globulin postpartum?
To prevent Rh sensitization in Rh-negative patients who have had fetomaternal transfusion of Rh-positive fetal red blood cells.
**Eg Fetus was positive, winrho wasn't given during pregnancy, there was a complication in delivery (PROM/PPROM etc)**
145
When should Rh immune globulin be administered postpartum?
Within 72 hours after delivery.
146
How does Rh immune globulin work?
It promotes the lysis of fetal Rh-positive red blood cells before the client’s immune system can form antibodies against them.
147
What is the usual dosage of Rh immune globulin?
300 mcg
148
How is Rh immune globulin dosing adjusted if a large fetomaternal hemorrhage is suspected?
Dosing is adjusted based on the Kleihauer-Betke test.
149
What is a key consideration for a postpartum client receiving both the rubella vaccine and Rh immune globulin?
Rh immune globulin may blunt the immune response to the live rubella vaccine.
Ensure pt has follow-up rubella titres assessed to confirm immunity
Re-vaccination may be required if titres remain low.
150
What are the core discharge criteria for a postpartum patient and infant?
– The health of the dyad is stable
– The client is able and confident to care for the infant
– There are adequate support systems in place
– The client has access to follow-up care
– Additional discharge considerations can be found in Box 22-1 (p. 566) of the textbook
151
Why is thoughtful planning of care important during the short postpartum hospital stay?
Because postpartum stays are brief in Canada, nurses must use this time to optimize health education and ensure clients are prepared for discharge.
152
What factors influence length of stay in the hospital during the postpartum period?
LOS is influenced by:
- physical condition of the dyad
- emotional status
- social supports at home
- patient education needs
- financial constraints.
Some clients may prefer to stay longer for observation and support, but vaginal births with no complications are often discharged quickly.
153
When should the nurse first initiate discharge planning?
**On admission and initial contact with the labouring parent**
Early recognition of potential barriers allows us to address them sooner rather than later.
Even applies in the ED. Consider what supports can be implemented earlier in order to optimize the length of stay.
154
When can couples safely resume sexual activity postpartum, and what factors influence this decision?
Risk of infection and hemorrhage is minimal after **2 weeks**.
Some couples may resume sexual activity before the 6-week checkup.
Readiness is influenced
- fear of pain
- healing perineal trauma
- vaginal dryness dyspareunia.
155
What causes dyspareunia postpartum, and how can it be managed?
**Decrease in estrogen + progesterone --> thinning of mucosa**
Discomfort is often due to vaginal dryness from hormonal shifts
Lubricants and discussing readiness with a provider can help.
156
How soon can ovulation occur postpartum, and what factors affect timing?
As early as 1 month postpartum. especially if **not breastfeeding**.
For lactating clients, ovulation is typically delayed up to 6 months due to lactational amenorrhea.
157
Why is it important to discuss contraceptive planning during pregnancy and postpartum?
To prevent unplanned pregnancies.
Ovulation can return unexpectedly.
Early counseling allows clients to choose suitable methods based on future plans/lactation/comfort with contraception
158
Why does breastfeeding delay the return of ovulation postpartum?
Breastfeeding increases PROLACTIN --> prolactin suppresses GnRH
Reduced GnRH secretion prevents LH and FSH from triggering ovulation
159
What are safe contraceptive options for breastfeeding patients?
Lactational amenorrhea method
condoms
hormonal methods compatible with breastfeeding
160
Contraceptives to AVOID for breastfeeding patients
**Estrogen-containing contraceptives** should be avoided early, as they can reduce milk supply.
161
What is the minimum recommended interpregnancy interval (IPI)?
At least 6 months.
162
What is the SOGC and WHO recommendation for ideal interpregnancy intervals?
SOGC recommends 18 months. WHO recommends 24 months between pregnancies.
163
What complications are associated with short interpregnancy intervals?
Uterine abruption
preterm labor
uterine rupture (especially with VBAC)
increased maternal mortality
164
Why is a short interval between pregnancies a concern for clients with previous C-sections?
A short interval increases the risk of uterine rupture during a TOLAC
Significantly raising maternal mortality risk.
