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Explain puerium
- Postpartum
- 6 weeks post-delivery
- 4th stage of labor
- 4th Trimester
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3 periods of postpartum and their time periods
- 1. Immediate: 1st 24hrs
- 2. Early: 1st week
- 3. Late: 2nd - 6th week
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Define Postpartum
- Body Recovers
- Goes back to prepregnancy state
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Shrinking or returning to normal size of uterus, cervix and vagina
Involution
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While giving a uterine massage what should you support?
Lower uterine segment
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While giving a uterine fundus massage what position should the bed be in
Flat
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When you are massaging the fundus what could be a possible complication if you don't have the pt .....
Empty Bladder
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What things will delay uterine involution?
- Full Bladder
- Any condition that over distends the uterus(multifetal pregnancies, hydramnios)
- Epidural
- Maternal Exhaustion
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How are you VS going to differ from the normal person, immediately postpartum?
- Temp slightly elevated within the first 24hrs
- Slow pulse, 50 bpm, for the first week
- BP should be normal
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Most rapid changes pp occurs in what time frame?
1st 3-4 days
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When dorsiflexing the foot the woman experiences pain
Positive Homan's Sign
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Fundal Height Times
Immediately After Delivery:
1. Firm in the midline and 1/2 way between the umbilicus and symphysis pubis
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Fundal Height
One hour PP
uterus should be contracted firmly with the fundus at the level of the umbilicus
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Fundal Height
1 day after PP
1 fingerbreath (1 cm) below umbilicus
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Fundal Height
Anything after the first day
1 fingerbreath per day untill no longer papable
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When should the fundus be no longer palpable
By the 10th day
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What promotes involution
- Breastfeeding
- Early ambulation
- Proper Nourishment
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What factors inhibit involution
- over distention of uterus
- retainted placental fragments
- infection
- grand multiparity
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When the uterus doens't contract effectivly what could this lead to
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5 or more pregnancies
Grand Multiparity
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How is involution assessed?
Measuring fundal height
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3 phases that occur in maternal adaptation
- Takin IN
- Takin Hold
- Letting Go
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3 ways bleeding is controlled phsiologically immediately after delivery
- 1.Involution and contraction causes to open blood vessels and seal them off
- 2. Clotting cascade is initiated
- 3. Fibrinogen levels are raised
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What are signs that the mother is not bonding with baby
- Turning away
- Negative statements about baby
- Refusing to name baby
- Not caring for baby
- Not wanting baby in room
- Gradual withdrawls
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Group of related symptoms
Syndrome
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Spongy soft uterus not well contracted
Boggy Uterus
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When the uterus is not contracting effectively; blood and clots collect in uterus which could lead to what
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Afterpains are most severe in ? because ?
Multipara because the uterus goes through periods of contraction and relaxation
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When massaging the fudus what are we assesing?
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If you over massage the fundus what could happen
Uterus becomes flaccid rather than helping it to contract
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The blood, mucus, tissue and WBC's make up this
Lochia
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Describe Lochia Rubra
- 1st 3-4 days
- Red in color
- Fleshy smell
- Small to Moderate Amount
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Decribe Lochia Serosa
- Days 4-10
- Small Amount
- Brownish-Pinkish Color
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Decribe Lochia alba
- After day 10
- White, or Pale Yellow in Color
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How long does lochia last?
2-3 weeks but could last up to 6 weeks
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3 abnormal findings to watch for in lochia
- 1. Reverse in Pattern
- 2. Fall to decrease or Increases
- 3. Foul odor
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Ovulation can occur as early as
3 weeks PP
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Ovulation can occur in the absence of
Menstrual Period
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A menstrual period can occur in the absence of
Ovulation
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This suppresses ovulation but is NOT an effective form of birth control
Breastfeeing
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A PP cervix may appear
Bruised and Torn
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What appearance does a nulliparous cervix have
Dimpled
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What appearance does a PP cervix have?
Slit-like doesn't ever go back to original shape
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When does Rugae return to vaginal walls?
3 weeks PP
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Breastfeeding can lead to dryness of the vaginal walls which leads to
Dyspareunia: painful intercourse
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What 2 things can cause prolactin levels to rise
- 1. Delivery of placenta (estrogen and progesteron levels fall causing prolactin to rise)
- 2. Suckling
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When does milk usually come in?
3rd Day
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What is the average amount of blood loss in a vag delivery
300-500mL
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What is the average amount of blood loss in a c-section?
500-1000mL
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As PP blood volume returns to normal you can expect an increase in what?
Hct
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High plasma fibrinogen levels at PP help bleeding stop but can cause what to occur?
DVT
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PP Blood Loss
For every 250mL of blood loss the Hct & hgb do what
- Hct: Fall 2 points
- Hgb: Fall 1 point
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WBC's do what in PP
Raise
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Immediate PP mom begins to shiver what do you do?
- Assess for temp, if over 100.4 this means infection
- If less than 100.4, give her a warm blanket or two
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Abdominal wall seperates during pregnancy leaving part of abd wall without muscular support
Diastasis recti abdominis
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4 risk factors for Diastasis recti abdominis
- Obese
- Over distended abdomen
- Poor Muscle Tone
- Grand Multipara
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Diminished peristalsis, hemrrhoidal pain, perineal discomfort, and iron supplements can lead to what
Constipation
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PP bowel function should return to normal when?
End of the 1st week
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When palpating the fundus if it deviates to the right it is because
Urinary Retention
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Approximately how many pounds are lost with the expulsion of the fetus, placenta, and amniotic fluid
10-12
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How many pounds is lost from fluid loss in early PP
5
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The average woman returns to her prepregnancy wt when?
6 mths PP
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What does breastfeeding do to your body
Helps you loose wt faster
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Reva Rubin identified 3 phases the PP woman goes through
- Taking In
- Taking Hold
- Letting Go
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Explain Taking In
When the woman is mostly concerned with her self
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Explain Taking Hold
When the woman begins to focus her care on the newborn
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Explain Letting Go
Woman begins to degine her role as a new parent
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The enduring emotional bond that develops between a mother and her infant
Attachment
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Initial component of healthy attachment is the the process of
Bonding
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Face to Face Bonding
En Face
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Approx 50-70% of all PP women experience a mild depression that lasts 2-3 days generally called
Postpertum Blues
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If a woman is goin to hemorrhage she is most likely to do so when
1st hour postpartum
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What 13 do you assess in a PP assessment
- VS
- Position and Firmness of Fundus
- Amount and character of Lochia
- Status of Perineum
- Bladder distention
- Incision if C-sect
- Breasts
- Homan's Sign
- Pain
- Bonding
- Emotional Status
- Any Labs
- Bowel
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How ofter do you assess VS
- 1st hr q 15min
- 2nd q 30min
- q 4hrs until 24hr mark
- Add a head to toe assessment each shift
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Check for what on Breasts
- Crackling
- Redness
- Engorgement
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Who has more lochia?
Vag Delivery
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Woman should be voiding what amout PP on a regular basis
100mL
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What position do you check the perineum in?
Sims
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We palpate the perineum with a gloved hand when checking for?
Hematoma's
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When you assess the calves what is the Norm?
- Equal in size bilaterally
- No red or painful areas when feet are dorsiflexed
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What labs do you need to order?
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When standing up lochia can alarm the woman because
- Lochia can pool up while sitting down
- Then once erect it may gush out and run down her legs
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What nursing interventions should you take for a boggy uterus?
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Bright Red Bleeding that occurs in a steady stream in the presence of a firm fundus is most likely to be caused by what?
Cervical Laceration that was not repaird
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Unilateral pain and swelling sometimes with hard mass in the breast could indicate
Mastitis
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What engorgement intervention should you provide for the breastfeeding mom
Warmth
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What nursing invention should you take for the mom who is feeding the infant formula
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Why should we give analgesics 30-45 mins before mom breastfeeds?
Reduce feeling of afterpains from uterine contraction due to oxytocin release from suckling
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What other nonpharm help with afterpains
Warmth
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Your pt complains of perineal pain...what is your next step?
- First visualize the perineum to rule out hematoma and that the episiotomy is well approximated
- Ice packs (20 min on/20 min off) 1st 24hrs
- Sitz Bath After 24hrs
- Mild analgesics with a narcotic
- Benzocaine Sprays
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Nursing interventions for hemorrhoids
- Sitz Bath
- Witch Hazel Pads
- Hydrocortisones
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Infection of the uterine lining
Endometritis
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Instruct the PP to change her pad q
4hrs
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What is used to clean the perineum
Perri Bottle
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First time mom is at risk for fainting the first time she showers because
Warm water causes peripheral blood vessels to dilate leading to hypotension resulting in fainting
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3 reasons to do an In & Out cath
- Distention
- 6 hours without void
- Several voids less than 100mL
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Anytime a narcotic is administered with a spinal or epidural what is a possible risk?
Respiratory Depression
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Report low RR when
Below 12 bpm
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Report a low pulse ox when
Less than 95%
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Abdominal surgeries such as c-sections cause gas to build up and manifests as pain where?
Shoulder
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Common side effect of narcotics usually fixed with benadryl
Pruritus
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How long is a cath left in with a c-sec birth
24hrs
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What should be available in the cse that hte meds cause RR of 12 or less
Narcan
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If the fundus is firm and the woman has no vaginal bleeding how often should you massage the fundus
YOU DON'T
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How often should you asses lung status after a c-sec
q 4 hrs
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How often should you TCDB
q 2hrs
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When the basal dose of analgesia doesn't control the pain adequately
Break through pain
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Research has shown it is easier to control pain when
Before it starts
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If pruritis becomes unberable what should your intervention be
Narcan
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Pain from flatus can be an issue after a c-sec so you need to teach your pt to avoid
- Very Hot or very cold drinks
- Soda
- Drinking through a straw
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Discharge day is focused on
Pt teaching
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Postpartum Danager Signs (12)
- Fever greater than 100.4
- Shaking Chills
- Localized reddened, painful area on one breast
- Frequency, Urgency, and Painful Urination
- SOB or Chest pains
- Severe unremitting abd or back pain
- Foul Smelling Lochia
- Increased in Heavy lochia or passage of clots
- Lochia pattern reversal
- Severe pain/reddness or swelling at epi site or incision
- Swollen painful reddened area on calf
- Prolonged or severe depression
- Thoughts of harming self or baby
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How many calories should the breastfeeding mom take in
500 more cal
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How many calories should a formula feeding mom cut out of her diet
300 cal
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What does mag sulfate do?
- Taken in toxic prevents seizures
- Sedates the nervous system to control B/P
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What can be done to help muscle tone
Kegal Exercise
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A falling in BP particularly in the presence of an increasing Pulse is suggestive of what
Hemorrhaging
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Is transient glycosuria, proteinura and ketouria normal in the 10th of PP
No just normal after immediate PP
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Dilation of renal pelvis and uters
Is this common
Due to what
Duration
- Hydronephrosis
- Yes
- Due to hormonal influences
- 4 weeks after delivery
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What is the nursing intervention for a Rh neg mom
RhoGAM injection withing 72hrs of delivery
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If mom is not immune to rubella what would you do?
- Administer vaccine
- PT TEACHING No pregnant within 3 months of injection
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Out put should be at what
30mL per hour
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Difference between C-Sec and Vag
- IV longer
- Longer to ambulate
- Diet
- No epi
- Abd incision
- Higher risk for gas pains
- Higher risk for infection
- More itching
- Cath longer
- Higher risk for Respiratory Disorders
- More pain
- Longer hospital stay
- higer risk for hemorrhage
- Decreased peristalsis
- Higher risk for thrombus formation
- Ausculatated more often
- Uterus descends faster
- More blood loss
- Less lochia
- Goes from rubra to serosa more quickly
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BUBBLE
- B: Breasts
- U: Uterus
- B: Bowel
- B: Bladder
- L: Lochia
- E: Epi/incision/ c-sec
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REEDA
- R: Redness
- E: Edema
- E: Ecchymosis (Brusing)
- D: Discharge
- A: Approximation
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