MB 4 Postpartum Sellers

first 6 weeks folowing birth

AKA puerperium

• 1. involution
• 2. wound healing
• 3. return to normal circulating volume
• 4. return to normal endocrine function
• 5. weight loss

process of shrinking of uterus to prepregnancy

almost doubled

during pregnancy have high levels of pregesterone and estrogen to sustain pregnancy then goes away PP

• 1. contraction of uterine muscle fibers
• 2. catabolism of enlarged uterine muscle cells
• 3. epithelial regeneration

shedding of the other portion of the endometrium and healing of the placental insertion site

pinches off vessels and prevents bleeding and causes uterus to get smaller

at the placental attachment site

will heal without scarring so that it does not interfere with future pregnancy implantations

~6 weeks

fundus will be midway b/t the pubic symphysis and the umbilicus

will rise to umbilical level due to inflammatory process and swelling

each subsequent day will descend by a fingerbreath

day 14

1. fibroids in the uterus

hemorrhage:  if fundus is a little high but firm and she is not bleeding excessivly that is fine

excessive bleeding, boggy uterus

uterine muscle contractions responsible for the descent of the uterus

• 1. feel like cramps
• 2. usually subside withing 48 hours

ibuprofen/NSAIDS

• 1. Rubra - through day 3
• 2. Serosa - days 4 - 10
• 3. Alba - seen day 11 and then tapers off

mostly blood with some decidual tissue and mucus - red

ask them what/where pain is to be sure this is what it is

NSAIDS are most effective

mostly serous with some erythrocytes, leukocytes, and mucus

pink-brown in color

made up of leukocytes, bacteria, some dcidual cells and epithelial cells, and mucus

white to light yellow

1. will pool while the pt is in a reclining position

2. will be less in a post-c section mom b/c more of the lining tissue is removed with the procedure

3. should not have a foul odor

should assess q 15 minutes for the first PP hour then q 4 h for the first 24 h

should assess color, amount, odor

may have excess lochia and possible clots from pooling of  blood while reclining

teach pt that this may occur

cervix will immediately be somewhat flaccid and possible edematous

withing a week will be firm and opening will be diminishing in size

will end up looking like a slit rather than a pinpoint opening

neck of the uterus

may be edematous, bruised, and have multiple small lacerations or episiotomy

will regain tone, but will always be slightly larger than before pregnancy occurred

cut in the perineal area

can take up to 6 months to heal

a tear will have a stronger heal r/t more fibers in diff areas

to prevent tearing of the rectal mucosa

redness, edema, ecchymosis, discharge, approximation

nothing in vagina until have next check-up in 6 weeks

no tampon, no sex, etc

vag - 500 mL

C-section - 1000mL

because of the increase in volume that occurred during the pregnancy

if they tried to push but didn't deliver the baby or if the delivered one twin then had the other Csection

1. blood to the uterus and placenta is shifted back into central circulation and causes increase in CO temporarily

2. decrease in pressure on the vessels b/c the heavy uterus is not longer compressing them

will be anemic by CBC b/c blood is dilute in pregnancy and will be even more anemic PP

almost all PP will be getting FE

increase CO -> increased SV -> body compensates by dropping HR -> temp bradycardia (50-60 BPM) in early PP

may temp increase r/t increased CO & increased volume r/t uterus getting less BF

hypovolemia

check pad

increased urination brought on by hormonal changes

perspiration

Need to teach the pt that these will occur

during PP period there is an increase in fibrinogen and clotting factors and decrease in fibrinolysis to prevent excess bleeding

break down of clots

early ambulation and mobility are important

• 1. vital signs: tachycardia and low BP = bad
• 2. fundus and lochia:  want firm fundus level with umbilicus and scant-moderate lochia
• 3. Homan's sign and exam of BLE (bilateral lower extremities) for color, temp, edema, pain, and pulses
• 4. DTR- deep tendon reflexes - for PP pre-eclampsia and will not have reflexes if no blood flow

will be hyper-reflexive

• 1. normal lochia - rubra, change colors in a couple days, should not be soaking pads q hour
• 2. should teach them that their circulatory system is changing and to change positions slowly, hot shower can cause vasodilation and lower BP
• 3. need to know they are at risk for falls and fainting

constipation and associated gas pain

• 1. decrese in motility
• 2. pain meds
• 3. pain from perineal trauma
• 4. manipulation of the gut during C-section
• 5. Fe supplements

positive sign of a return to normal function

nurses need to ask if they have been having any gas

stool softeners

full bladder can displace the fundus to the upper right quadrant - interferes with ability to contract and may lead to excessive bleeding

ask p to void or cath if necessary then massage the fundus

• 1. trauma to areas
• 2. epidural decreases sensation & reduces bladder control
• 3. if had Foley may have decreased bladder control or decreased ability to void

1. may have incontinence/ stress incontinence caused by displacement caused during pregnancy

2. may have difficulty voiding

muscle aches and pains

hormone relaxin diminishes as ligaments resume their pre-pregnant condition (tightens up)

abd muscles that are longitudinal - split during pregnancy

have pt do a crunch in bed and can feel muscles surrounding your hand

1. dramatic drop in estrogen and progesterone

2. prolactin increases

3. oxytoncin triggers letdown

delivery of the placenta triggers it

prolactin increases during preg but is inhibited by the presence of progesterone and estrogen 

after the placenta is delivered -> progesterone and estrogen decrease -> increased prolactin -> milk production

prolactin - milk production

oxytocin - milk letdown

• 1. return of menstruation
• 2. prolactin increase and lactation

1. lactation may delay menstruation but not necessarily ovulation

2. ovulatin may occur prior to the first menstruation

3. discuss conception and desire for contraception before they leave the hospital

cannot take the combo BC pills but there are some that they can take

• 1. initially, REEDA & circulatory assessments
• 2. assessment of bowel and bladder function
• 3. newborn care and teaching about complications
• 4. self-care and teaching and complications, S/S of infection, too much bleeding, avoiding per vagina, comfort measures
• 5. contraception and her options
• 6. assessment of bonding with the baby
• 7. pain management
• 8. any special considerations: Rhogam, rubella vaccine

need Rhogam shot within 72 hours of delivery

should not get pregnant again for at least 3 months

pertussis vaccine b/c keeps her from passing it to her baby

if test shows that she is not immune to rubella she will be given MMR before leaving

• 1. ice packs to the perineum
• 2. squirt bottles with warm water for use after voiding and BM
• 3. topical anesthetic sprays
• 4. warm water perineal soaks
• 5. pain meds
• 6. oral narcotic pain meds

may have pads with ice pack already inside or can pull out some stuffing from a pad and insert an ice pack

leave ice pack on until ice melts

remove for at least 10 minutes before replacing

watch out for -caine allergies

be sure to clean tub soaking in b/t soaks

NSAIDs r/t their anti-inflammatory action

ibuprofen, toradol

PCA

hydrocodone

• 1. taking in
• 2. taking hold
• 3. letting go

squirt off then pat dry

pat dry instead of wiping

will make the area numb

• 1. mother is focused on her own need for rest, food, etc
• 2. takes in every detail of her baby but is content to allow others to take the lead in caring for the child
• 3. char by reliving the details of the labor and birth

• 1. begins to reclaim responsibility for her own care
• 2. begins to focus on the baby and is eager to learn

• 1. change in family structure (no matter how many babies they have had) - mother will accept this in this stage
• 2.  may be a loss of child they imagined

when she is in the taking hold phase

1. teach pt that these feelings and stages occur

2. teach them that it is normal for them to feel some disappointment about the baby if it is different from their dream baby - allow them to talk about these feelings and accept their feelings

• 1. fingertipping - exploring baby with fingertips then whole hand then by embracing the baby close to her body
• 2. binding in - begins relating child's features and behaviors to the family - (brother's hair)
• 3. use of personal pronouns and the baby's name rather than it or the baby

1. model behaviors such as fingertipping and use of baby's name

2. ask questions such as "Whose nose do you think he has?"

3.Point out reciprocal attachment behaviors by the baby, such as grasping the mother's finger or gazing at the mother's face

4. provide ample opportunities to held the baby, but allow time for rest, eating, and show concern for mother's comfort

• 1. flat affect in general
• 2. baby always in the bassinet
• 3. not making eye contact with baby or doing bonding behaviors

• 1. PP blues
• 2. PP depression
• 3. PP psychosis

70-80%

transient and self-limiting

b/c hormones drop due to loss of placenta producing them

10-15%

can occur anytime in first year of birth but usually occurs in 2 wks-3 months

won't be seen in hospital usually

occurs in 1-2/1000 births

can occur as early as PP day 2

is an emergency

• 1. Hx of depression of other mental illness
• 2. first pregnancy
• 3. low self-esteem
• 4. teen pregnancy
• 5. family stressors
• 6. multiple gestations
• 7. health problems with the infant

• 1. depressed affect
• 2. loss of interest in usual activities
• 3. feelings of incompetency as a mother
• 4. symptoms persist more than 2 weeks

1anxiety, irritability, guilt, loss of sense of self, difficulty concentyrating, failure to eat, sleep disturbances, & suicidal thoughts

• 1. counseling for pt and family
• 2. medication
• 3. some cases require electroconvulsive therapy

do not wait to see if it lasts for 2 weeks - Tx if the S/S for depression are present

if they had it with previous pregnancies

1. selective seratonin reuptake inhibitors/SSRIs - EX:  effexor & zoloft

2. tricyclic antidepressants (TCAs)- EX:  elavil/amitriptyline

• 1. bizarre behavior
• 2. agitation
• 3. delusions
• 4. confusion
• 5. hallucinations

1. requires hospitalization to prevent suicide of infanticide

2. medical Tx with antipsychotics and antidepressants

break with reality

varying levels of estrogen and progestoerone during the ovulatory cycle trigger other hormonal changes that cause ovulation to occur

provides a consistant level of estrogen and progesterone which interupts the cycling of hormones in ovulatory cycle

• 1. pill
• 2. patch
• 3. ring
• 4. implants
• 5. depo provera injection

ortho evra

nuvaring

q 3 months

• 1. Hx of thrombosis
• 2. CVA
• 3. CAD
• 4. estrogen dependent cancer
• 5. breast cancer
• 6. poorly controlled HTN
• 7. DM with vascular compromise
• 8. some migraines (aura)
• 9. impaired liver function
• 10. undiagnosed vaginal bleeding
• 11. smoking >15 cigs/day or any smoking if over 35 years old
• 12. prolonged immobility
• 13. current pregnancy

most are diff combos of estrogen and progesterone or may be progesterone alone

usually involves taking high levels of progestin

does not harm implanted pregnancy

thickens cervical mucus to prevent sperm getting to the egg

may also delay or prevent ovulation

smoking

greater risk for thrombosis

• 1. condoms
• 2. spermicides
• 3. sponge
• 4. diaphrag/cervical cap
• 5. intrauterine device - some of these release hormones

ppl 17 and over can get OTC

pharmacies may be unwilling to sell it

teach pt do not need Rx

• 1. usually require monitoring signs of ovulation
• 2. some are strictly based on the number of days in the menstrual cycle
• 3. abstain from intercourse during the period just prior to and immediately following ovulation

better if combine barrier types:  spermicide and barrier

ova susceptible for ~ 24 h

sperm survive up to 80 hours

• 1. pull out doesn't work
• 2. do not douche after sex

• 1. contraindications may occur if health probs
• 2. smoking?

• 1. take temp
• 2. assessing discharge

1. bilateral tubal ligation

2. vasectomy

a lot of motivation and dedication

a lot of work involved

1. should know that this is considered permenant - if they are not sure don't do it

• 1. effectiveness
• 2. acceptibility - messiness, self-touch, religious beliefs, cultural norms
• 3. convenience and effect on spontaneity
• 4. side benefits - amenorrhea, acne & migraine reduction (1 contraceptive helps)
• 5. expense
• 6. involvement of others - partner, parent/guardian

how effective is it and how important is it for them to not get pregnant

younger ppl / adolescents

depo provera

• 1. how committed is partner
• 2. are there various partners

parent support and how much will they need parent help

inserted into the uterus - work by triggering inflammatory response & creating a hostile env for sperm

some (mirena) release low levels of progestin to thicken cervical mucus & sometimes prevent ovulation

can usually use mirena b/c low levels

a person who cannot take oral contraceptives can usually use IUD

person at high risk for STD's should not use IUDs due to increased risk of PID - if they regularly use condoms a person with mult sex partners can still use IUD

multiple partners and don't use condoms

PID & infertility

office procedure - through an introduction cannula -> through cervical opening -> pull out cannula and it opens up and stays in uterus (soft and flexible)- there are strings that will hang out (can be cut out if it is bothersome)

check placement of IUD

5 years and will not effect fertility long-term after taken out

10 years

form of IUD

yes

Pull string and it collapses in on itself and comes out

• 1. leek procedure for abnormal pap smear can cause scar tissue that prevents penetration
• 2. congenital anamaly that prevents insertion
• 3. ppl who have not had vaginal deliveries it can be difficult to insert and cause more cramping

barrier

soft and pliable

put spermacidal gel in cup and insert into cervix

must be fitted:  will need refitted after delivery or weight gain/loss, if don't feel comfortable touching themselves will not like it

leave in 8 hours after intercourse

do not leave in longer than 24 hours

impregnated with hormones, does not cover cervix

inserted into vagina and it expands, placement not critical, releases hormones

hormonal

hormonal

hip, butt, shoulder blades, upper arm

transdermal

medroxyprogesterone

IM injection q 90 days

7

depo provera

shot q 3 months

1. some change strength as go through cycle

2. some have same dose throughout cycle

lybrel

no, it cannot harm you to not have a period every month

have a period 4 times per year q 3 months

they can cause breakthrough breathing

• 1. hemorrhage
• 2. infection
• 3. thrombosis
• 4. depression and psychosis

primary - occurs within the first 24 hrs following birth

secondary - after first 24 hours

fluctuating so may be difficult to interpret

uterine atony

trauma to birth canal, retained placenta, coagulation defects

without tone

blood changes due to dilution during pregnancy and diuretic effects of PP period makes it fluctuate too much

uterine muscle does not contract prn in order to compress the blood vessels and stop bleeding

• 1. multiparity
• 2. multiple gestation
• 3. polyhydramnios
• 4. prolonged labor or precipitate labor
• 5. C/S
• 6. use of oxytocin in labor
• 7. manual placenta removal
• 8. uterine masses/fibroids

fatigue of the uterine muscle

• 1.massage the fundus
• 2. assess for bladder distention & treat
• 3. rapid infusion of dilute pitocin
• 4. methergine
• 5. various prostaglandins
• 6. push IV fluids - lactated ringers
• 7. transfuse with whole blood or packed RBC
• 8. last resort = historectomy

IM ONLY!!

potent vasoconstrictor

• 1. contracts uterus
• 2. expel clots to allow uterus to be able to contract

massage the fundus!!!

have then void or in and out cath

hemabate, prostin, cytotec

stimulate uterine contractions

lactated ringers

any time the fundus is firm but excessive bleeding is present

often require surgery for repair

• 1. delayed involution
• 2. retained placental fragments
• 3. infection

6 - 14 days PP

need to teach pt S/S b/c will usually occur after left hospital

1. similar to primary hemorrhage:  oxytocin, prostaglandins

2. ultrasound eval of the utrus for placental fragments or clots may be done

3. dilation and curettage for fragment removal

4. antibiotics for infection

• 1. bimanual uterine massage by MD
• 2. use of a ballooon tamponade for direct compression within the uterus
• 3. ligation of uterine arteries
• 4. hysterectomy

constricting peripheral vessels to shunt blood to vital organs & releasing catecholemines

compensatory mechanisms will fail ->  organs fail due to blood shunted away from them-> lactic acid builds up = metabolic acidosis

vasodilation that can increase bleeding

may be gushing or cont. trickle

make sure you look under them for pooling blood

may be forming a hematoma somewhere - need to inspect the perineum for hematoma

REEDA

may initially remain stable

tachycardia, narrowing pulse pressure, tachypnea

• 1. pallor
• 2. coolness
• 3. decrease in UOP b/c of blood shunted away from kidneys
• 4. anxiety & sense of dread
• 5. confustion
• 6. lethargy

difference b/t systolic and diastolic pressures

• emergency!!
• 1. v/s q 3 to 5 minutes
• 2. fundal and lochia assessment and massage
• 3. o2 sats
• 4. foley for I& O recording
• 5. O2 by nonrebreather facemask 8 to 10 L/min
• 6. IV access and rapid infusion
• 7. transfusion - will need large IV

usually occurs in a varicosity (varicose vein)

• 1. little risk of pulm embolus
• 2. vein may be hardened

may complain of leg pain during ambulation

• 1. rest
• 2. compression support - TEDS
• 3. elevation
• 4. heat therapy
• 5. antiinflammatory meds
• 6. ambulate gradually when s/s have resolved

venous return

occur in deeper and often larger vessels

significant risk of pulm embolus

• 1. may be asymptomatic
• 2. edema
• 3. erythema
• 4. change in temp:  warmer or cooler
• 5. tenderness
• 6. + Homan's sign
• 7. pallor of the limb
• 8. decreased pulses
• 9. pain with ambulation
• 10. malaise

• 1. doppler flow studies
• 2. CT scan or MRI
• 3. D-dimer blood test

helpful to rule it out

if it is negetive means there isn't a DVT

if it is positive can be # of conditions but could have a DVT

• 1. bedrest with limb elevation
• 2. no massage of the limb
• 3. pain control
• 4. anticoagulant therapy

1. initially cont IV heparin

2. prior to discontinuation of heparin will also begin warfarin

3. will remain on warfarin for up to 6 months

used to det the app. dosing for the pt and may vary widely from pt to pt

1. monitor aPTT on heparin

2. monitor PT/INR on warfarin

3. Monitor for S/S of toxicity:  bruising, bleeding gums or nose, blood in urine, stool, petechiae, signs of blood loss

no

infection

• 1. endometritis
• 2. wound infections
• 3. UTI
• 4. mastitis
• 5. septic pelvic thrombophlebitis

q 6 h until get to therapeutic level then qd

infection of the uterus

person with prolonged rupture of membranes or long period of time before delivery, post C-section, colonization of reproductive tract (GBS), DM

if baby doesn't latch on properly can crack nipples and get infected

group A&B strep, E.coli, chlamydia is ass. with late endometritis

huge risk for infection

1. risk for endometritis

2. risk for baby getting infection

• 1. fever - primary sign
• 2. subinvolution - uterus larger than should be
• 3. abd pain and tenderness - really sensitive during fundal massage
• 4. purulent/foul smelling lochia
• 5. elevated WBC

usually within first 2 days PP

• 1. IV antibiotics
• 2. promote drainage - elevate HOB
• 3. pain management
• 4. monitor VS & WBC count

monitor WBC count

to promote drainage

episiotomy/tear

C-section incision

make sure follow MD orders for dressings etc

cone/wedge-shaped redness, edema, heat, pain, systemic symptoms (fever, malaise, may be very nauseated)

antibiotics and pump, pump, pump or cont to breastfeed

continue to nurse - will not harm the baby

do not nurse- must pump until healed

only when it is close to the areaola and will be where the baby's mouth will be

begin by nursing on the unaffected side - will stim the let-down so minimal nursing is required on the painful breast to achieve emptying

• 1. may use ice or heat - heat before nursing
• 2. breast support but not compression
• 3. breast massage
• 4. increase fluids

heat therapy

infection that courses through the venous sytem of the pelvis and causes thrombophlebitis of these vessels

2 probs:  infection -> triggers thrombus formation

will have s/s of infection and thrombophlebitis: 

• 1. s/s of infection
• 2. groin pain
• 3. abd pain
• 4. if GI involved will have hypoactive bowel sounds
• 5. N/V
• 6. cramping

will be more GI s/s such as N/V along with s/s infection

fever that does not respond to antibiotics

ABX & anticoagulants

there is inflammation ass. with thrombophlebitis that contributes to fever and does not respond to ABX