week 8: postpartum care Flashcards
what is the postpartum period
referred to as “4th trimester”
- lasts approx 6 wks after birth
- interval between birth and return of reproductive organs to normal nonpregnant state
- approach to care after birth is wellness orientated
what is a 1st degree perineal laceration
lacerations extends thru the skin and structures superficial to muscles
what is 2nd degree perineal lacerations
extends thru muscles of perineal body
what is a 3rd degree perineal laceration
continues thru anal sphincter muscle
what is 4th degree perineal laceration
involve anterior rectal wall
what are risk factors of perineal lacerations
- precipitous labour
- macrosomia/post dates
- maternal anatomy
- positive (shoulder dystocia/breech)
- instrument use (forceps)
what are preventative measures for perineal lacerations
warm compress on perineum. peri-massage. favourable positions.
how long does healing of perineal lacerations take
~2wk for initial heal, ~4-6 mo for complete healing
tears are often smaller than an episiotomy true or false
true (still risk for further tearing)
routine episiotomy is recommended in Canada true or false
false
what is an episiotomy
incision in perineum to enlarge vaginal outlet
- In Canada 17% reported
- midline is most common: effective, easily repaired and least painful, increased risk of 3rd or 4th degree lacerations
- mediolateral: prevention of 4th lacerations, greater blood loss, repair is more difficult and more painful
what is vaginal, urethral, and cervical lacerations
- vaginal lacerations occur in conjunction with perineal lacerations
- extend up lateral walls and high in the vaginal vault
- cervical injuries result when the cervix retracts over the advancing head (delivering the fetus before full dilation)
- cervical injuries can have adverse effects on future pregnancies and childbirths
what kind of care should be provided for vaginal, urethral, and cervical lacerations
- squirt bottle (warm water with no soap). when starting to urinate, start squirting (it dilates the acidity of the pee). when done peeing, squat again and pat dry.
- for BM “splint”: put toilet paper at the perineum during BM to support the perineum
- ice packs in 1st 24h
- warm therapy post 24h
- change pads q2h (even if not saturated, since we want to reduce risk of infection
in the bp postpartum finding what normal and whats a potential complication
normal: consistent BP; orthostatic hypotension for 48hrs (sudden change in transabdominal pressure)
potential complication: HTN (anxiety, preeclampsia - can develop 6 wk postpartum, even if you didn’t have it during labour. Hypotension (PPH).
in the HR postpartum finding what normal and whats a potential complication
norm: 60-100 bpm
potential complications: tachycardia (pain, fever, dehydration, PPH)
in the RR postpartum finding what normal and whats a potential complication
norm: 16-24 breath/min
potential complications: tachypnea (anxiety, resp distress), bradypnea (narcotic medications)
in the temp postpartum finding what normal and whats a potential complication
36.2-38 degrees celcius
- may be elevated in 1st 24 hrs r/t dehydration (common if given an epidural)
potential complication: febrile (infection), possibly due to GBS +’ve, several in/out catheters, retained placenta, mastitis, several vaginal exams
in the pain postpartum finding what normal and whats a potential complication
normal: mild pain from uterine cramping.
potential complication: severe pain
if normal blood loss during delivery, hematocrit levels _____________________ and then begin to _______________________ postpartum.
- hematocrit levels drop for 3-4 days
- begin to increase to prepregnancy level by 8 weeks postpartum
what happens to postpartum WBC
increase (leukocytosis and increased ESR may obscure the diagnosis of acute infection)
what happens to clotting factors and fibrinogen in the immediate postpartum period
remain elevated. risk for thromboembolism. encourage early ambulation. some clients require anticoagulants. (especially for c-section deliveries)
refer to SOGC guidelines regarding venous thromboembolism and antithrombotic therapy in pregnancy
describe changes in the endocrine system in the postpartum period
- expulsion of placenta results in rapid decrease in hormones (estrogen, progesterone, cortisol, hCG, hPL, and placental enzyme insulinase)
- prolactin levels increase after birth (influenced by method of feeding)
- lactating and nonlactating clients differ considerably in the timing of their first ovulation and then menstruation resumes
if breastfeeding: ovulation begins ~6 mo
if not breastfeeding: ovulation begins after ~3 mo
describe postpartum recovery area
- after initial recovery period of 1-2 hrs, clients may be transferred to postpartum room
- in some facilities, clients labour, birth, recovers, and spends the postpartum period in the same room (LBRP)
- communication btwn nurses is important when transferring care
- promotion of rest and recovery
- facilitating attachment within the family
- establish infant feeding
- emphasis on health teaching
whats a normal voiding ability in postpartum
200-600 mL
when are we concerned w blood loss in postpartum
> 500 mL
look at lochia.
concerned if:
- 1 pad is saturated in 15 mins, or 2 pads are saturated in 1 hr
describe postpartum assessment (BUBBLLEE)
B = breast (firmness) and nipples
U = uterine fundus (location, tone)
B = bladder function (amount, frequency, dysfunction)
B = bowel (passing gas or bowel movement)
L = lochia (amount, colour)
L = legs (edema)
E = episiotomy/laceration/c-section birth incision
E = emotional status (mood, fatigue)
post partum assessment of the breasts
- days 1-2
- days 2-3
- days 3-5
+ potential complications
- soft
- filling
- full, soften with breastfeeding
nipples intact with no soreness.
- engorgement: firmness, heat, pain
- mastitis: redness of breast tissue, heat, pain, fever, body aches
- trauma from latching: redness, bruising, cracks, fissures, abrasions, blisters
non-breastfeeding client considerations
- endocrine sys controls the initial production of colostrum
- breast tenderness and engorgement may occur
- temporary congestion of veins and lymphatic rather than accumulation of milk
- discomfort normally lasts 24-36 hours
to relieve engorgement, clients should be encouraged to hand express. true/false.
false, it stimulates. more milk to be expressed.
fresh cabbage leaves can be applied to the breasts. true/false.
true, absorbs some fluids
mild analgesia such as tylenol and ibuprofen are effective treatment options. true/false?
true.
clients should be encouraged to wear a well-fitted sports bra.
true, helps bind breasts and support them. just don’t use underwire bras.
describe mastitis
- unilateral, localized redness
- warm and redness
- firmness in milk ducts
- pain/swelling
- flu-like symptoms (if fever present, give antibiotics)
- most likely in <2 mo, less common >6 mo
- typically occurs of abrupt stop of breastfeeding and blocks milk ducts
the uterus at full term weight approx __________ times it pregnancy weight
11 (~1000g @ term, ~60-80 normally)
describe uterine contractions postpartum
- hemostasis is achieved by compression of intramyometrial blood vessels oppose to clot formation
- oxytocin released from posterior pituitary gland and exogenous oxytocin during 3rd stage of labour
- breastfeeding immediately after birth and after increases the release of oxytocin
- coordinated and strong contractions
which client is most likely to experience increased uterine afterpains?
1. primigravida that delivered at 38 wks to a singleton
2. multigravida that delivered at 40 wks with polyhydramnios and a LGA infant
3. multigravida that had a precipitous delivery
- since uterus was very stretched and now takes more work to return to original
definition of uterine involution
involution: return of the uterus to nonpregnant state
- process begins with expulsion of placenta
- rapid decrease in estrogen and progesterone result in autolysis of hypertrophied tissue in the uterus
how do you palpate and massage a fundus
upper hand is cupped over fundus
lower hand dips is above symphysis pubis and supports uterus while it is massaged gently
where should the uterus be normally
midline and firm
what happens immediately after birth where is the fundus what does it feel like
fundus at umbilicus to 2 cm below
- firm = basketball
- boggy = 1/2 deflated basketball
what happens within 12 hours after birth
fundus may rise to 1 cm above the umbilicus
24 hours after birth, what is the uterus like
equal to the same size as 20 wks gestation
every 24 hours what does the fundus do
continues to descend 1-2 cm every 24 hours
by day 6 postpartum what is the fundus like
fundus is halfway between the umbilicus and symphysis pubis
at how many weeks should the uterus not be palpable abdominally
2 weeks
what is subinvolution, and common reasons for occurance
failure of the uterus to return to a nonpregnant state
- common reasons: retained fragments and infection
describe uterine atony, and risks for this
failure of uterine muscle to contract firmly (boggy/soft uterus)
most common cause of excessive bleeding (PPH)
risks: retained placental fragments, hematomas, unrepaired lacerations, uterine overdistension
describe a normal lochia
1. day 1-3
2. day 4-10
3. after 10 days
- rubra (dark red)
- serosa (brownish red or pink)
- alba (yellowish white)
lochia often lasts 4-8 weeks postpartum
the amount of lochia is usually less after a c-section birth true or false
true, surgeon often suctions some out
the flow of lochia often increases with ambulation true/false
true
a perineal pas saturated in how many minutes of less is of immediate concern
15 min
how do you assess lochia
under clients buttocks, must roll pt to assess their bleeding. excessive blood loss goes undetected as blood can flow between the buttock and under the client.
how do you assess a cesarean incision
REEDA
R = redness
E = edema
E = ecchymosis (bruising)
D = drainage
A = approximation
- activity restrictions
health teaching for postpartum
- frequent hand hygiene before and after peri care
- frequently change peri pads
- ice packs (1st 24 hrs)
- use warm water in the peri bottle with each void
- gently pat dry from urethra to anus
- no use of tampons
- kegel exercises
- sitz baths
- topical applications
what is kegel exercises
- pelvic muscle exercises to strength and support the pelvic floor
- instruct the client to pretend they are trying to stop the flow of urine midstream
- hold contraction for at least 10 sec, rest for 10 sec
- positive outcomes with kegel exercises for 15 mins BID
describe the urinary system postpartum
- initial decrease in kidney function; resumes to normal by 1 month postpartum
- preg induced hypotonia and dilation of the ureters resolves by 6 wks postpartum
- within 12 hrs after birth, begin to lose excess tissue fluid
- profuse diaphoresis for first 2-3 days
- birth induced trauma, increased bladder capacity following childbirth and epidural/spinal decrease the urge to void, tenderness for lacerations when voiding
what to watch our for immediately after postpartum as a nurse
- excessive bleeding can occur if the bladder becomes overdistended
- pushes the uterus up and to the side
- prevents it from contracting firmly
later concerns postpartum to watch out for nurses
- overdistension increases risk of infection
- bladder tone not restored
bowel functions postpartum
- BM may not occur for 2-3 days postpartum
- tenderness related to hemorrhoids, episiotomy, lacerations
- fluids, fiber, ambulation encouraged. stool softeners may be required.
- instrumental vaginal births (forceps or vacuum) and 4th degree tear are associated with increased risk of anal incontinence
what is the rubella vaccination
- recommended for clients that are non-immune (titer of 1:8 or enzyme immunoassay levels less than 0.8)
- SQ injection postpartum
- live attenuated
- prevents the possibililty of contracting rubella in future pregnancies
- compatible with breastfeeding
- vaccine is teratogenic, avoid conception one month after vaccine
Rh Immune Globulin
- considered blood product
- admin within 72 hrs postpartum
- prevents sensitization in Rh-negative client who had a fetomaternal transfusion of Rh-positive fetal RBC
- Rh immune globulin promotes lysis of fetal Rh-positive blood cells before client can form their own antibodies against them
- usual dosing is 300 mcg
- if large fetomaternal transfusion suspected, dosing may be adjusted based on Kleihauer-Betke test
kleihauer-betke test
blood test used to measure the amount of fetal hemoglobin transferred from a fetus to a mother’s bloodstream
what are considerations for a client that receives both rubella vaccine and Rh immune globulin?
the MMR vaccine is a live vaccine, and the Rh IG suppresses immune response, so the vaccine will be less responsive. you must return after a month or so to check titer levels.
discharge criteria for postpartum
- health of dyad is stable
- client is albe and confident to provide care for the infant
- adequate support systems in place
- access to follow up care
when should the nurse first initiate discharge planning?
a) on admission and initial contact with the labouring client
b) immediately after birth
c) during postpartum period when family is rested
d) when healthcare provider writes discharge orders
a
sexual activity and contraception in postpartum period
- clients may be reluctant to resume sexual activity due to fear of pain or damaging healing perineal area
- risk of infection or hemorrhage is minimal after 2 wks
- some couples may resume sexual activity before traditional 6-wk postpartum check up
- dryness and coital discomfort (dyspareunia) may persist until return of ovarian function
- ovulation can occur as soon as 1 month postpartum, especially if the client is not lactating
- for breastfeeding client, lactational amenorrhea method, condoms, or hormonal methods of birth control (once milk supply established)
what should be told to pt regarding interpregnancy intervals
- individuals should be advised to avoid interpregnancy intervals shorter than 6 months
- counseled about the risks and benefits of repeat pregnancy sooner than 18 months
- greater risk of complications: IPI is less than 6 mo, previous history of preterm birth, prior c-section and trial of labour uterine rupture and maternal mortality
