WH Postpartum

Question 1

Recovery stage: the first 2 hours of postpartum

Answer 1

Fourth stage of labor

Question 2

The first 6-8 weeks following a birth

Answer 2

Postpartum (puerperium)

Question 3

Bonding, adjusting to parenthood, learning infant care

Answer 3

Psychological processes of postpartum

Question 4

Uterine involution, lochia flow, breastmilk formation, diaphoresis, diuresis

Answer 4

Physiological processes of postpartum

Question 5

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

Answer 5

Postpartum Nursing Interventions

Question 6

stimulated by oxytocin. The release of this is stimulated by breastfeeding

Answer 6

Uterine involution

Question 7

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

Answer 7

Fundal height

Question 8

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

Answer 8

Postpartum uterus

Question 9

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

Answer 9

Lochia and blood loss

Question 10

Red discharge, day 1-3

Answer 10

Rubra

Question 11

pink, brown, day 4-10

Answer 11

Serosa

Question 12

pink-yellow-white, day 10-8 weeks

Answer 12

Alba

Question 13

Interventions: Notify provider.
Monitor VS
Start IV if no current access
Administer meds as ordered

Answer 13

Interventions with Excessive bleeding

Question 14

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

Answer 14

Postpartum perineum

Question 15

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.

Answer 15

Hemorrhoids

Question 16

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.

Answer 16

Postpartum constipation

Question 17

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

Answer 17

Postpartum Bladder

Question 18

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)

Answer 18

Postpartum Breasts

Question 19

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

Answer 19

Breastfeeding Latch

Question 20

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.

Answer 20

Poor feeding effort

Question 21

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

Answer 21

Mastitis

Question 22

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

Answer 22

Plugged milk duct

Question 23

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

Answer 23

Postpartum extremities

Question 24

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

Answer 24

Postpartum Danger Signs

Question 25

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.

Answer 25

Postpartum Psychological

Question 26

Talking to infant, face to face, eye contact. Naming infant, identifying family characteristics. Touching, physical contact, feeding, diapering. Responding to infant cries.

Answer 26

Good signs of bonding

Question 27

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

Answer 27

Warning signs of poor bonding

Question 28

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

Answer 28

Postpartum families

Question 29

BUBBLEHEE exam

Answer 29

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

Question 30

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

Answer 30

Postpartum Tests and Vaccines

Question 31

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

Answer 31

Postpartum Lochia and Menses (period)

Question 32

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

Answer 32

Postpartum Discharge Teaching and Planning (1 of 2)

Question 33

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.

Answer 33

Postpartum Discharge Teaching and Planning (1 of 2)

Question 34

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.

Answer 34

Postpartum sexual activity

Question 35

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

Answer 35

Warning signs of late complications

Question 36

Depressed mood in the first 10 days with mood swings, tearfulness, feeling letdown, anxious or angry

Answer 36

Postpartum "Blues"

Question 37

True depression within the first 12 months, persistent sadness or intense mood swings which do not resolve, 15% or more of new mothers affected

Answer 37

PP depression

Question 38

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

Answer 38

PP psychosis

Question 39

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.

Answer 39

Postpartum DVT

Question 40

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

Answer 40

Treament and Nursing Interventions for Postpartum DVT

Question 41

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

Answer 41

Postpartum Pulmonary Embolism S/s and interventions

Question 42

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.

Answer 42

Postpartum Hematoma

Question 43

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

Answer 43

Postpartum Hematoma Interventions

Question 44

Blood loss of more than 1000ml or either vaginal or c/sec delivery, although blood loss of more tha 500ml warrants close monitoring

Answer 44

Postpartum hemorrhage (PPH)

Question 45

Common causes: Uterine atony, uncontrolled bleeding from a laceration or repair, placental abruption or previa, retained placenta or placental fragments

Answer 45

Causes of Postpartum hemorrhage

Question 46

Prior hemorrhage or coagulopathy, high parity, overdistended uterus (multiples, polyhydramnios), long labor, dystocia, prolonged pitocin admin, precipitous labor, mag sulfate admin

Answer 46

Risk factors for atony and PPH

Question 47

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

Answer 47

S/s of postpartum hemorrhage

Question 48

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

Answer 48

Nursing Interventions during severe PPH

Question 49

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)

Answer 49

Uterine Atony

Question 50

Monitor uterine tone and vaginal bleeding. monitor VS. Maintain IV fluids. Maintain empty bladder. Express clots from uterus. ASSESS FOR MED SIDE EFFECTS

Answer 50

Uterine Atony Nursing Interventions

Question 51

Enlarged uterus which continues to bleed without normal involution process. Usually requires dilation and curettage to remove fragments and antibiotics for infection

Answer 51

Subinvolution of the uterus

Question 52

Risk factors: Uterine infection (endometritis), retained placental fragments or trapped blood clots.

Answer 52

Risk factors for subinvolution of the uterus

Question 53

Prolonged or irregular vaginal bleeding, enlarged uterus, tender or boggy uterus.

Answer 53

S/s of subinvolution of the uterus

Question 54

Uterine infection, usually presents day 3 postpartum. Diagnosis may require collecton of vaginal and blood cultures

Answer 54

Endometritis

Question 55

S/s: Pelvic pain or uterine tenderness, chills, fatigue, malodorous lochia, fever, tachycardia. Treatment: IV antibiotics

Answer 55

S/s and Treatment of Endometritis