WH Postpartum Flashcards
Recovery stage: the first 2 hours of postpartum
Fourth stage of labor
The first 6-8 weeks following a birth
Postpartum (puerperium)
Bonding, adjusting to parenthood, learning infant care
Psychological processes of postpartum
Uterine involution, lochia flow, breastmilk formation, diaphoresis, diuresis
Physiological processes of postpartum
Assess for complications: PPH, shock, infection
Q15m assess BP, pulse, uterine tone and position, lochia flow (bleeding)
Admin Pitocin or alternate oxytocic med
Provide comfort and support pt with first ambulation and void (watch for orthostatis hypotension). Education. Promote bonding. promote breastfeeding if desired by family, otherwise support formula feeds
Postpartum Nursing Interventions
stimulated by oxytocin. The release of this is stimulated by breastfeeding
Uterine involution
at umbilicus right after delivery, decreases one fingerbreadth per day. Documentation of 1 finder below umbilicus looks like U/1. Documentation of 2 fingers above is recorded as 2/U
Fundal height
After 10 days-2 weeks, the uterus is not palpable abdominally. A “boggy” or relaxed uterus will usually respond to abdominal massage and quickly become firm
Postpartum uterus
EBL (estimated blood loss) and QBL (quatitative blood loss) are measured at birth and in recovery, ongoing significant bleeding is weighed and added into the cumulative blood loss for delivery.
Assess for quantity, color, odor (if any) and consistency.
Quantity: scnat, light, moderate, heavy, saturated pad or excessive (soaking a pad in 15 min, pooling on bedding or linens). If heavy or excessive , weigh on a scale (subtract weight of pad or linens ) for QBL
Color: Rubra, serosa, alba
Consistency: assess for clots
Lochia and blood loss
Red discharge, day 1-3
Rubra
pink, brown, day 4-10
Serosa
pink-yellow-white, day 10-8 weeks
Alba
Interventions: Notify provider.
Monitor VS
Start IV if no current access
Administer meds as ordered
Interventions with Excessive bleeding
Often with some edema or bruising.
Assess approximation and note any drainage (light bleeding cann be normal)
Heals quickly 3-4 weeks dependingn on depth, however full depth healing and sensation can take months.
Ice for first 24 hours, stool softener
Taching: pt to use peri bottle to rinse area adn then pat drym topical anesthetic spray prn, clean front to back
Postpartum perineum
Common in pregnancy and following pushing efforts, treat with medications, ice, witch hazel as needed for pain, may contribute to consipation issues as women may avoid BMs.
Hemorrhoids
Folowing labor there is often a delay in resumption of bowel movements for 1-2 days. If normal peristalsis does not resume, this can happen signficantly and ileus formation can occur. Often laxative or stool softeners are given each day postpartum to avoid these complicatons. Enemas and rectal med prepa re contriandicated in pts who have had a third or fourth degree repair (dont disrupt sutures). Encourage fluids, ambulation, and high fiber foods.
Postpartum constipation
Assess for distention. Sensation may be decreased and a woman may not recognize need to void. Increased diuresis should be notable within 12h of delivery. Up to 3L/day can be eliminated in first few days postpartum. Pain with urination (dysuria) due to a laceration can be improved with pain meds, urinating in warm water (bath or shower), use of peribottle or anesthetic spray
Postpartum Bladder
Colostrum is present and may be leaking prior to labor and birth. Transitions to mature milk on day 3-4, turns white, “comes in” with breast filling and engorgement, may be uncomfortable and dramatic with erythema and breast firmness. No meds given to inhibit milk production. “use it or lose it”. If milk supply is not breastfed or pumped, the body will stop production over the course of many days. If a woman is choosing not to breastfeed, she can aply cabbage leaves inside of bra to breast to inhibit breastmilk. For comfort, supportive bra, cold packs, avoid nipple stimulation.
To encourage milk production, feed frequently, eat and hydrate well, get rest, decrease pain and stress
Breastfeeding is feed on demand but at least every 3 to 4 hours in the first week
Assess ofr unilateral erythema (mastitis), cracked or bleeding nipples (from a poor latch), tenderness or masses (plugged milk duct)
Postpartum Breasts
The way that the baby attaches to the breast. If inadequate, can damage the nipple and feedings are painful. The infant needs a wide open mouth before latching in order to get the entire nipple and aerola into its mouth, just suckling on the tip of the nipple will not supply milk and will harm the mother
Breastfeeding Latch
The baby must do the work, timing is everything. Mother need encouragement to repeatedly offer feedings before an infant is too tired or upset to feed well. Babies who do not feed early may become sverely hypoglycemic, breastfeeding can go well one feeding then be impossible two hours later. Lactation consultatns are available to help with frurations.
Poor feeding effort
An infection within the milk duct, symptoms are unliateral pain, erythema, warmth, fever, and general malaise (flu-like symptoms)/ Continue breastfeeding to prevent milk stasis. The infection will NOT hurt the baby
Mastitis
A blockage of flow of the milk in the duct. A firm mass with discomfort and pressure. The mother can apply heat to try to massage toward the nipple to free the blockage
Plugged milk duct
Edema- may worsen after delivery due to fluids given in labor, should be symmetrical
Unilateral leg swelling, redness and warmth can indicate venous thrombus
Encourage ambulation, adequate fluids, compression stockings or pressure devices for non-ambulatory patients
Postpartum extremities
Tachycardia: Initially PP women can be tachycardic due to exertion, but one recovered, normal PP pulse can be low as 40 due to increased stroke volume so a resumption of tachycardia is a red flag
Fever: anything beyond 100.4 is significant (can be med related if given misoprostol)
Change from baseline: with so many variables, always compare to pregnancy baseline vitals
Postpartum Danger Signs
Wide range of emotions can be “normal”. Often tearful but quickly returning to normal affect. Observe for bonding, demonstrating desire to care for infant and to learn, asking question.
Postpartum Psychological
Talking to infant, face to face, eye contact. Naming infant, identifying family characteristics. Touching, physical contact, feeding, diapering. Responding to infant cries.
Good signs of bonding
Ignoring cries. Irritation with spitting up, wet diapers or stools. Leaving infant across room, not holding or touching. Interpreting infant as uncooperative or if infant doesnt like them. Not wanting to touch warrants consultation. Anxiety is normal but not nortmal when parent is unable to act or care for baby. Watch for signs of depression: not eating, not sleeping, avoiding interaction
Warning signs of poor bonding
Healthy babies left in mothers room for the family to learn to care and bond with infant. Taking infant for few hours at night is common but infant care is primarily on the parents. Parents need teaching and encouragement with every nursing interaction when learning to care for first child. Seasoned parents may need much less support. Fathers and coparents may go through same emotions but can have disappointments or jealousy. Siblings are concerned about their need for attention. Siblings should have clost contact with mothers and have attention from other family members during moms recovery. Concerning sibling behaviors are aggression, attention seeking behaviors, or regression in normal habits
Postpartum families
BUBBLEHEE exam
VS and pain assessment
Breasts: nipples intact skin red or tender, filling or firm with milk supply
Uterus: fundal heigh, tone firm or boggy (asses with pt supine and supporting lower segment)
Bowels: bowel sounds, passing stool or gas, tolerating normal diet.
Bladder: distended, voiding freely
Lochia: color and amount (assess while palpating the fundus)
Episiotomy or laceration: assess perineum for ecchymosis, edema, approximation
Homan’s Sign: Dorsiflexes foot, positive for DVT if pain
Education: parent concerns or questions, routine teaching
Emotions: Affect, adjustment to parenthood, concerns
Rubella vaccine should be given PP if not immune. Varicella may also be given. TDAP should be given if not already given during prenatal care.
Rhogam given within 72h of birth to RH neg mother with RH positive baby. CBC ordered for excessive bleeding, PPH, or post c/sec.
Remember: coagulation factors and fibrinogen levels continue to be increased immediately postpartum. Beneficial when dealing with heavy bleeding. Increases risk of thrombus formation and thromboembolism
Postpartum Tests and Vaccines
Resolution: around 8 weeks
Resumption of period varies depending on duration of lactation and frequency of breastmilk feedings (breastmilk can be pumped and then bottle fed to infant). Lactation stimulates prolactin whch supresses ovulation.
Period usually resumes 6 months with breastfeeding but can take year or longer.
Ovulation may resume 7 weeks after delivery if not lactating, usually period resume around 12 weeks
Postpartum Lochia and Menses (period)
Important to understand level of support at home or any housing or safety issues- addressed during prenatal care and upon hospital admission
Avoid strenuous activity until bleeding has stopped (could be 6-8 weeks). Limit stair climbing and walks, shopping, etc until bleeding has slowed and sleep schedule improved. Women race to get into shape and cause themselves to endure more bleeding, more pain and end up depressed and exhausted.
Review warning signs for complications
Review warning signs for P depression as this progresses over weeks to months
Review infant care
Postpartum Discharge Teaching and Planning (1 of 2)
Encourage rest and naps, sleep when baby sleeps. Continue prenatal vitamins until supply is gone or 6 weeks. Inform of contraceptive options prior to discharge postpartum. If contraception is chosen, it is started at 6 week check up. Many methods can be started in hospital for those who wont return for follow up, high anxiety related to pregnanacy, will lose health insurance or simply desire it.
Postpartum Discharge Teaching and Planning (1 of 2)
Wait until bleeding is stopped and perineum is healed, varies depending on laceration. Recommend lubrication. Arousal for the mother is dimished by fatigue, fear of pain, anxiety about getting pregnant, lactation hormones and constant presence of a little human.
Postpartum sexual activity
Infection: malaise, fever 100.4 or higher, body aches, excessive fatigue, chills, foul odor
Hemorrhage: increasing bleeding, steady heavy flow, passage of large clots
Mastitis: pain, erythema, hard lump in one breast, fever, malaise, chills
Incision or wound infection: increasing pain, opening of incision, pus, erythema, edema
Depression or psychosis: unable to perform infant care or ADL, persistent sadness or crying, expressing desire for self harm or thoughts of harming the baby, acts of self harm, educate family members as well of these warning signs.
DVT: pain in one calf, localized lump or mass, unilateral leg edema, localized warmth or tenderness
Warning signs of late complications
Depressed mood in the first 10 days with mood swings, tearfulness, feeling letdown, anxious or angry
Postpartum “Blues”
True depression within the first 12 months, persistent sadness or intense mood swings which do not resolve, 15% or more of new mothers affected
PP depression
Usually present in the first 3 weeks, increased risk of bipolar, characterized by disorientation, hallucinations, obsessive behaviors, paranoia, or attempts at self harm or harm to the baby, requires medical intervention and often hospitalization
PP psychosis
A thrombus in the deep veins of the leg. Can become dislodged and then lead to PE. High risk when postpartum, double the risk when c/sec or surgery.
Other risk factors: Operative delivery, varicosities, immobility, obesity, somoking, multiparity, AMA, history or prior PE or DVT
High risk pts put on heparin or lovenox PP.
Postpartum DVT
Treatment: elevate leg, warm moist compresses, NO massage, measure leg circumference, meds.
Nursing interventions: SCDs if immobile. Encourage ambulation. Compression hose for varicosities. Educate: ambulate, avoid prolonged standing or sitting or crossing the legs, elevate legs
Treament and Nursing Interventions for Postpartum DVT
S/s: Anxiety or apprehension, chest wall pain, dyspnea, tachypnea, hemoptysis, tachycardia, cough, syncope, crackles, fever, hypoxia
Nursing interventions: Place semi fowlers, administer oxygen, meds as ordered
Postpartum Pulmonary Embolism S/s and interventions
Large blood collection within deep tissues. Can be pelvic or vaginial. May be visible as a bulge or occult (hidden from sight). Usually produces intense pain and pressure
Risk factors: Difficult or operative delivery, precipitous birth, CPD, macrosomia, prior vaginal scarring or trauma.
Postpartum Hematoma
Interventions: Inspect and palpate for signs, assess and treat for pain, closely monitor vitals, notify provider as these usually require operative repair (quite extensive and requiring anesthesia), ice packs
Postpartum Hematoma Interventions
Blood loss of more than 1000ml or either vaginal or c/sec delivery, although blood loss of more tha 500ml warrants close monitoring
Postpartum hemorrhage (PPH)
Common causes: Uterine atony, uncontrolled bleeding from a laceration or repair, placental abruption or previa, retained placenta or placental fragments
Causes of Postpartum hemorrhage
Prior hemorrhage or coagulopathy, high parity, overdistended uterus (multiples, polyhydramnios), long labor, dystocia, prolonged pitocin admin, precipitous labor, mag sulfate admin
Risk factors for atony and PPH
Overt bleeding (saturating pads, pooling blood) or passage of large clots. Uterine atony “boggy”. Constant trickling of bright red blood. Tachycardia and hypotension. Pallor, cool and clammy skin. Oliguria
S/s of postpartum hemorrhage
Call for help. Will need several members to handle this emergency. Uterine massage, assess VS, assess for bleeding source. Catheterize bladder if distended. Ensure IV access, replace fluid loss with NS or LR. Quantify bleeding. Monitor O2 sat, supply oxygen if indicated. If syncopal, elevate legs to increase central perfusion. Assist with blood product admin if needed. Assist with surgery if needed
Nursing Interventions during severe PPH
Meds for this condition and their side effects:
Oxytocin: water intoxication (N and V, headache, malaise, lightheadedness)
Methylergonovine: hypertension (DO NOT give to hypertensive pts), N and V, headache
Carboprost: fever, hypertension, chills, headache, N and V, diarrhea
Misoprostol: fever (if given high dose)
Uterine Atony
Monitor uterine tone and vaginal bleeding. monitor VS. Maintain IV fluids. Maintain empty bladder. Express clots from uterus. ASSESS FOR MED SIDE EFFECTS
Uterine Atony Nursing Interventions
Enlarged uterus which continues to bleed without normal involution process. Usually requires dilation and curettage to remove fragments and antibiotics for infection
Subinvolution of the uterus
Risk factors: Uterine infection (endometritis), retained placental fragments or trapped blood clots.
Risk factors for subinvolution of the uterus
Prolonged or irregular vaginal bleeding, enlarged uterus, tender or boggy uterus.
S/s of subinvolution of the uterus
Uterine infection, usually presents day 3 postpartum. Diagnosis may require collecton of vaginal and blood cultures
Endometritis
S/s: Pelvic pain or uterine tenderness, chills, fatigue, malodorous lochia, fever, tachycardia.
Treatment: IV antibiotics
S/s and Treatment of Endometritis
