-
puerperium or postpartum (4th trimester)
- def
- begins when
- continues for how long
- period in which the woman readjusts physically and psychologically from pregnancy and birth
- immediately after birth
- approximately 6 wks or until body retruns to near nonpregnant state
-
reproductive systems changes
- involution of the uterus
- changes in fundul position
- lochia
- cervical changes
- vaginal changes
- perineal changes
- reoccurance of ovulation and menstration
-
uterine involution
- def
- ___________ is important aspect of involution
- assessed by measuring
- rapid reduction in uterine size and return to near nonpregnant state (slightly larger than before 1st pregnancy)
- exfoliation
- fundal height
-
factors that enhance involution
- uncomplicated labor and delivery
- complete expulsion of amniotic membranes and placenta
- breastfeeding
- manual removal of placenta during cesarean birth
- early ambulation
-
factors that retard involution
- prolonged labor
- anesthesia
- full bladder
- difficult birth
- gradmultiparity
- incomplete expulsion of placenta or membranes
- infection
- overdistention of uterus
-
changes in fudal position
- after delivery
- 6-12 hrs after birth
- 1st pp day
- until and on 10th day
- situated midline 1/2 to 2/3 of way between symphysis pubis and umbilicus
- rises to level of umbilicus, remains about 1/2 day
- located 1cm below umbilicus
- descends approx 1 fingerbreadth/day until descended into pelvis on 10th day
-
Lochia
- Rubra
- Serosa
- Alba
- 1-3 days (dark red)
- 3-10 days (pinkish color)
- 10 days to 2 wks (creamy, yellowish)
-
postpartal cervial changes
may be spongy, flabby, formless and may appear bruised. original form should be regained within a few hours
-
postpartal vaginal changes
may appear bruised, edematous and gaping; ruge are gone. the vagina reduces in size and rugae return within 3 wks. non-lactating woman should have a normal appearing vagina by 6 wks
-
postpartal perineal changes
soft tissue may appear edematous with some bruising. episiotomy or laceration may be present
-
postpartal reoccurance of ovulation and menstruation
should return in non-lactating mothers between 6-10 wks after birth. the first cycle is anovulatory in about 50% ofmothers. in lactating mothers it can return as early as 2mos. or as late as 18 mos.
-
postpartal changes to the abdomen
- uterine liigaments are stretched
- abdominal wall appears loose and flabby
- striae (strech marks) may be present from stretching and rupture of elastic fibers of the skin
-
postpartal abdominal assessment
- assess bowel sounds
- assess for diastatsis recti abdominis
- assess uterine tenderness
-
potpartal urinary tract changes
- _________ bladder capacity, ________ and _________ of urethral tissues; _________sensitivity to fluid pressure and __________ sensation of bladder filling - all caused by _______ and ______
- puerperal diuresis - (def)
- more prone to ? (3)
increased, swelling and bruising, decreased, decreased
causes increased urinary output in the first 12-24 hrs
UTI, hematuria, proteinuria
-
postpartal vital signs
- temp (after birth)
- temp (after milk)
- BP
- HR
- may be elevated to 38C (100.4F) for up to 24 hrs after birth
- may be increased for 24 hrs after the milk comes in
- rises early and then returns to normal
- Bradycardia occurs during the first 6-10 days
-
postpartal blood values
- WBC
- blood loss
- plasma
- platelets
- cardiac output
- will also have?
- nonpathologic leukocytosis occurs in early PP
- blood loss averages 200-500ml (vaginal), 700-1000ml (cesarean)
- plasma levels reach the prepregnant state by 4-6 wks PP
- returns to normal by 6-12 wks
- diuresis
-
Other normal PP changes
- weight loss
- postpartal chill
- postpartal diaphoresis
- afterpains
- 10-12lbs (infant, placenta, fluid) diuresis accounts for 5lbs. should return to prepregnant weight by 6-8 wks (if gained avg 25-30 lbs)
- intense tremors that resemble shivering immediately after birth; common, self-limiting
- sweating may occur at night
- caused by intermittent uterine ctxs, occurs more often in multiparas, multiple gestations, and polyhydramnios
-
"Taking In"
- when
- def
"Taking hold"
- when
- def
- PP days 1-2
- mother tends to be passive, somewhat dependent, hesitant about making decisions, preoccupied with her needs (food and sleep major needs)
- PP days 2-3
- mother ready to resume control over her body, her mothering and her life in general
-
Maternal Role Attainment (MRA)
- def
- Four Stages
- Mercer (1995) describes MRA as process by which woman learns mothering behaviors and becomes comfortable with her identity as a mother
- Anticipatory Stage
- Formal stage
- Informal stage
- Personal stage
-
Postpartum Blues
- def
- periods
- what attributes to it
- transient periods of depression; sometimes occurs during first few days PP
- mood swings, anger, weapiness, anorexia, diff sleeping, feeling let down
- changing hormones, lack of supportive environment
-
principles of conducting a PP assessment
- select time that will provide themost accurate data
- provide explanation
- ensure woman is relaxed
- record and report clear results
- body fluid precautions
- excellent opp for teaching
-
PP Assessment tool
BUBBLEHE
- Breast
- Uterus
- Bowel
- Bladder
- Lochia
- Episiotomy/Lacerations
- Homans'/Hemmorhoids
- Emotions
-
PP Breast Assessment
- Size and Shape
- Abnormalities, reddened areas, or engorgement
- prescence of brest fullness due to milk presence
- assess nipples for cracks, fissures, soreness, or inversion
- if breastfeeding, assess LATCH (audible, type of nipple, comfort, hold/positioning)
-
PP abdominal assessment
- position of fundus related to mubilicus
- position of fundus to midline
- firmness
- assess incision for bleeding, approximation, and signs of infection
-
PP Assessment of Lochia and Perineum
- assess lochia for amount, color, and odor
- presence of any clots
- wound is assess for REEDA
- presence of hemorrhoids
- level of comfort/discomfort
- efficacy of any comfort measures
-
PP assessment of extremities, bowel and bladder
- Homans's sign
- assess calf for redness and warmth
- adequacy of urinary elimination
- bladder distention and pain during urination
- intestinal elimination
- maternal concerns regarding bowel movements
-
PP assessment of psychological adaptation and nutrition
- adaptation to motherhood
- fatigue
- nutritional status
- cesarean birth - return of bowel function, tolerance of dietary progression
- physical and developmental tasks - gain competence in caregiving, confidence in role as parent, return of all physical systems to prepregnant state
-
PP Nursing interventions
- activity/mobility - assist OOB 1st time, then prn; encourage frequent rest and ambulation
- nutrition
- elimination
- comfort - pericare, sitz bath, topical and PO analgesics
- medications - Rubella vaccine, Rhogam
-
Home Care Teaching
- warning signs (when to call provider)
- infant care
- self care
- contraception
- resumption of sexual activity
-
Postpartum Hemorrhage
- Early
- Late
Immediate or Primary - occurs in 1st 24 hrs after childbirth
Secondary - occurs from 24hrs to 6 wks after birth (less common)
-
Causes of PP Hemorrhage
- Uterine atony (relaxation of uterus)
- - overdistention of uterus
- - preeclampsia
- - intra-amniotic infusion
- - use of MgSO4 in labor
- Retained placental fragments
- Laceration of genital tract
- Vulvar, vaginal, or subperitoneal hematomas
- Coagulation disorders
-
Signs of PP hemorrhage
- excessive or bright red bleeding
- boggy fundus that does not respond to massage
- abnormal clots
- unusual pelvic discomfort or backache
- persistent bleeding in the presence of a firmly contract uterus
- rise in the level of the fundus of the uterus
- increased HR or decreased BP
- hematoma formation or bulging/shiny skin in the perineal area
-
Assessment of PP Hemorrhage
- fundul height and tone
- vaginal bleeding
- signs of hypvolemic shock
- development of coagulation problems
- signs of anemia
-
Nursing interventions for PP hemorrhage
- uterine massage if a soft, boggy uterus is detected
- encourage frequent voiding or catherize the woman
- ice packs to perineum for lcient at risk for hematoma formation
- vascular access
- type and screen available
- assess lab results (esp Hct)
- administer oxytocics, uterine stimulants per MD order
- assess level of discomfort and administer analgesics as needed
- assess urininary output
- encourage rest and take safety precautions
-
prevention and teaching r/t pp hemorrhage
- adequate prenatal care
- good nutrition
- avoidance of traumatic procedures
- risk assessment
- early recognition and mgt of complications
-
PP infection
- reproductive tract or pueperal infections
- wound infection
- urinary tract infection
- other
- endometritis (metritis), pelvic cellulitis (parametritis)
- perineal, ceserean
- cystitis, pyelonephritis
- mastitis
-
mastitis
- def
- begins when
- organisms
- unilateral infection of breast connective tissue that occurs primarily in breast feeding women
- when bacteria invade traumatized breast tissue
- Staph, H influenza, E coli, Strep; candida albicans if baby develops thrush
-
assessment of PP infection
- REEDA
- fever malaise
- abd pain
- foul smelling lochia
- larger than expected uterus
- tachycardia
-
assessment of cystitis
- frequency and urgency
- dysuria
- nocturia
- hematuria
- elevated temp
-
if pyelonephritis developes look for?
systemic systems - chills, high fever, CVAT, N/V
-
assessment of mastitis
- breast consistency
- skin color
- surface temp
- nipple condition
- presence of pain
-
Nursing intervention for pueperal/wound infections
- Labs and cultures
- IV/PO antibiotics
- I&D if abscess present
- sitz bath and localized heat
- adequate PO/IV hydration
- analgesic meds
- wound packing
-
nursing intervention of UTI
- clean catch or cath UA with C&S, CBC
- antibiotics (IV for pyelonephritis)
- encourage fluid intake
- antispasmodics, analgesics, and antipyretic meds as needed
-
nursing interventions for mastitis
- encourage supportive bra, frequent breastfeeding, fluid intake, rest
- antibiotics (may do C&S)
- local application of heat
- analgesics and NSAIDS as needed
-
prevention and teaching
- good perineal care
- hygiene practices to preven contamination of the perineum, wipe front to back
- thorough hand washing
- sitz baths
- adequate fluid intake
- diet high in protein and Vit C
- frequent voiding, before and post intercourse
- cotton underwear
-
prevention and teaching for mastitis
- proper feeding techniques
- supportive bra worn at all times to avoid milk stasis
- good handwashing
- prompt attention to blocked milk ducts
-
Thromboembolic disease
- refers primarily to superficial thrombophlebitis (thrombus d/t inflammation)
- superficial thrombophlebitis
- DVT
- PE
-
assessment of thrombophlebitis
- homan's sign
- pain in the leg, inguinal area or lower abd
- edema
- temp change
- pain with palpation
-
nursing interventions for thrombophlebitis
- monitor VS (esp temp)
- inspect and palpate calf, thigh and groin area daily for heat, color, tenderness and peripheral pulses
- measure calf circumfrence
- bedrest then initiate progressive ambulation after acute inflammation subsides
- elevate and apply warm compresses to affect extremity
-
nursing interventions for thrombophlebitis
- Heparin therapy (DVT)
- - monitor PT
- - assess for bleeding
- - protamine sulfate
- antibiotics if fever present
- monitor and report any signs of PE (vague CP, anxiety, tachypnea, pallor, changes in lung sounds)
-
prevention and teaching r/t thrombophlebitis
- early ambulation
- uncrossed legs
- avoid prolonged sitting or standing
- elevate feet when sitting if possible
- wear support hose
- adequeate fluid intake
- precautions if taking anticoagulants
-
PP psychiatric disorders
- potpartum blues
- postpartum psychosis
- postpartum depression
-
assessment of PP psychiatric disorders
- depression scales - edinburgh postnatal depression scale; beck pospartum depression prdictor inventory (PDPI)
- anxiety and irritability
- poor concentration and forgetfullness
- sleeping dificulties
- appetite change
- fatigue and tearfulness
-
nursing intervention for PP psychiatric probs
- help parents understand the lefestyle changes and role demands
- provide realistic info
- anticipatory guidance
- dispel myths about the perfect mother fo the perfect newborn
- educate about the possibility of postpartum blues
- educate about the symptoms of postpartum depression
|
|
