1. 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
  2. reproductive systems changes
    • involution of the uterus
    • changes in fundul position
    • lochia
    • cervical changes
    • vaginal changes
    • perineal changes
    • reoccurance of ovulation and menstration
  3. 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
  4. 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
  5. factors that retard involution
    • prolonged labor
    • anesthesia
    • full bladder
    • difficult birth
    • gradmultiparity
    • incomplete expulsion of placenta or membranes
    • infection
    • overdistention of uterus
  6. 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
  7. Lochia
    - Rubra
    - Serosa
    - Alba
    • 1-3 days (dark red)
    • 3-10 days (pinkish color)
    • 10 days to 2 wks (creamy, yellowish)
  8. postpartal cervial changes
    may be spongy, flabby, formless and may appear bruised. original form should be regained within a few hours
  9. 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
  10. postpartal perineal changes
    soft tissue may appear edematous with some bruising. episiotomy or laceration may be present
  11. 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.
  12. 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
  13. postpartal abdominal assessment
    • assess bowel sounds
    • assess for diastatsis recti abdominis
    • assess uterine tenderness
  14. 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
  15. 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
  16. 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
  17. 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
  18. "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
  19. 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
  20. 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
  21. 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
  22. PP Assessment tool
    • Breast
    • Uterus
    • Bowel
    • Bladder
    • Lochia
    • Episiotomy/Lacerations
    • Homans'/Hemmorhoids
    • Emotions
  23. 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)
  24. PP abdominal assessment
    • position of fundus related to mubilicus
    • position of fundus to midline
    • firmness
    • assess incision for bleeding, approximation, and signs of infection
  25. 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
  26. 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
  27. 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
  28. 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
  29. Home Care Teaching
    • warning signs (when to call provider)
    • infant care
    • self care
    • contraception
    • resumption of sexual activity
  30. 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)
  31. 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
  32. 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
  33. Assessment of PP Hemorrhage
    • fundul height and tone
    • vaginal bleeding
    • signs of hypvolemic shock
    • development of coagulation problems
    • signs of anemia
  34. 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
  35. prevention and teaching r/t pp hemorrhage
    • adequate prenatal care
    • good nutrition
    • avoidance of traumatic procedures
    • risk assessment
    • early recognition and mgt of complications
  36. PP infection
    - reproductive tract or pueperal infections
    - wound infection
    - urinary tract infection
    - other
    • endometritis (metritis), pelvic cellulitis (parametritis)
    • perineal, ceserean
    • cystitis, pyelonephritis
    • mastitis
  37. 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
  38. assessment of PP infection
    • REEDA
    • fever malaise
    • abd pain
    • foul smelling lochia
    • larger than expected uterus
    • tachycardia
  39. assessment of cystitis
    • frequency and urgency
    • dysuria
    • nocturia
    • hematuria
    • elevated temp
  40. if pyelonephritis developes look for?
    systemic systems - chills, high fever, CVAT, N/V
  41. assessment of mastitis
    • breast consistency
    • skin color
    • surface temp
    • nipple condition
    • presence of pain
  42. 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
  43. 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
  44. 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
  45. 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
  46. 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
  47. Thromboembolic disease
    • refers primarily to superficial thrombophlebitis (thrombus d/t inflammation)
    • superficial thrombophlebitis
    • DVT
    • PE
  48. assessment of thrombophlebitis
    • homan's sign
    • pain in the leg, inguinal area or lower abd
    • edema
    • temp change
    • pain with palpation
  49. 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
  50. 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)
  51. 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
  52. PP psychiatric disorders
    • potpartum blues
    • postpartum psychosis
    • postpartum depression
  53. 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
  54. 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
Card Set