PostPartum (class 11 & 12)

puerperium

the period of about six weeks after __childbirth__ during which the mother's reproductive organs return to their original __nonpregnant__ condition.

return of reproductive organs to their pre pregnant state

puerperium

first 42 days into postpartum period

puerperium

there is a trend to early discharge. therefore teaching in harder to do.. so _______ education is very important

prenatal

If the mother is Rh-negative

her immune system treats Rh-positive fetal cells as if they were a foreign substance.

If mother is ____, Rhogam is given

Rh negative

If mother is Rh negative, then ________ is given

rhogam

Give RhoGam within the first ____ hrs. Helps break down RBCs so mom doesn’t make antibodies. 

72

________________ may arise from:


1. High risk medical conditions that predate pregnancy e.g. heart disease
2. Arise during pregnancy e.g. preeclampsia

3\. Intrapartum events e.g. placenta previa,

Postpartum complications

loss of > 500ml of blood after vaginal birth, or 1000ml after c/s.

is the leading cause of maternal morbidity and mortality postpartum.

postpartum hemorrhage

Post partum hemorrage

 definitions have changed in that any blood loss that has the potential to cause hemodynamic instability should be considered PPH.

early postpartum hemorrhage

\-within 24hr after birth.

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\-uterine atony

\-lacerations of the birth canal

\-DIC

\-trauma eg. inversion of uterus

late post partum hemorrhage

\-24 hrs or more after birth

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\-subinvolution due to retained placental fragments

\-hematoma, bleeding, infection

Urinary tract infections

\-very vulnerable during post partum

\-etiology … usually bacterial (e.coli)

predisposing factors for UTI’s

\-birth trauma to bladder,

\-urethra, meatus;

\-Dilation of the ureters and pelves during pregnancy;

\-Hypotonicity of the lower urinary tract;

\- History of UTI;

\- Repeated or prolonged catheterizations, poor technique;

\-Cesarean section,

\-forceps and vacuum births, and induction of labour;

\-Frequent pelvic exams

UTI s/s

V/S- tachycardia,

low-grade fever,

dysuria (Painful urination),

frequency and urgency,

suprapubic and lower abdominal pain,

dark urine with foul odour

UTI prevention

proper perineal care,

frequent bladder emptying,

encourage fluids

UTI treatment

antibiotics, analgesics, hydration

Inflammation of breast tissue

mastitis

mastitis is most commonly from

staph aureus

mastitis:

_______________ provide a portal of entry for the organism; once the bacteria enter the breast tissue milk, stasis provides the medium for proliferation

cracked nipples

Mastitis s/s

fever, chills, localized warmth, swelling, and tenderness.

May be enlarged axillary nodes. May develop abscess (painful collection of pus)

prevention of mastitis

hand washing,

breast care - wash with warm water (no soap, removes protective oils),

let breast milk dry on nipples,

clean bra, no plastic liners,

good BF techniques – prevent cracked nipples, alternate positions

If someone has mastitis.. they should empty breast q___-___ hours by breastfeeding, manual expression, or breast pump

2-4

management of mastitis

Encourage bra - supports and reduces pain.

Heat or ice packs to reduce engorgement, pain, warm compresses before feeds.

Empty breasts q2-4h by breastfeeding, manual expression, or breast pump.

Adequate hydration.

Analgesics, antibiotics as ordered.

Rest.

Emotional support.

mastitis is mostly ________.

unilateral

mastitis can be from _____ of milk

stasis

what is the most common infection? (it often begins at placental site and may spread to entire endometrium

endometritis

endometritis s/s

fever, ↑ pulse, chills, anorexia, lethargy, lower abdominal pain, fundal tenderness, foul smelling profuse lochia

endometritis usually manifests _ to _ hours after delivery

24-72

cause of endometritis is invasion of body by ?

normal flora

management of endometritis:

•Antibiotics and analgesics

•Semi-fowler’s position

•Good perinatal hygiene

•Encourage fluids (3-4L)

•Maximize rest

•Comfort measures

• Teaching!

what position should someone who has endometritis be in?

semi-fowlers

infection of the lining of the uterus

endometritis

Incidence of endometritis is higher after _____ birth

Caeseran

__________ and a markedly increased _____ sedimentation rate are typical laboratory findings of postpartum infections

Leukocytosis .

RBC

puerperal or postpartum infections

Reproductive system infection occurring during the postpartum period

Predisposing factors for post partum infections ?

* Invasive interventions such as PROM, prolonged labour, repeated PV exams, intrauterine manipulation, C/S, fetal scalp electrodes, etc..

modes of entry of organisms for postpartum infection

* Breasts
* Endometrium
* Perineal tears
* Urine
* Sexual activity
* IV
* Catheter

s/s of post partum infection

* presence of a fever of 38° C (100.4° F) or more on 2 successive days of the first 10 postpartum days (not counting the first 24 hours after birth)
* 5 Cardinal Signs (heat, pain, inflammation, redness, drainage)

Puerperal or Postpartum Infections: Assessment

If T ≥ 38°C following birth, exclusive of the first 24 hours

• Low grade temps common and considered normal-dehydration, breast engorgement etc...)

• A temp of 38°C during the first 24 hours is considered an indicator of early infection.

Formation of a clot (s) inside a blood vessel caused by inflammation or partial obstruction of the vessel

Thromboembolic disorders

types of thromboembolic disorders

\-SVT

\-DVT

\-pulmonary embolism

superficial venous thrombosis (SVT)

confined to superficial

saphenous system. Referred to as phlebitis

deep venous thrombosis

Involves deep veins of legs. Can extend from foot to iliofemoral region. Not associated with

inflammation but with obstruction & clot formation

pulmonary embolism

when portion of the clot breaks free, is carried through the circulation, and lodges in the pulmonary artery

risk factors for thromboembolic disorders

* Delayed ambulation 
* venous stasis and hypercoagulation, both of which are present in pregnancy and continue into the postpartum period
* Caesarean birth nearly doubles the risk for VTE 
* operative vaginal birth
* history of venous thrombosis, PE, or varicosities
* Obesity
* maternal age over 35 
* multiparity
* smoking

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s/s of SVT

* unilateral pain and tenderness in lower extremity, usually below knee, warmth, reddened, enlarged, hardened vein over site of thrombus

s/s of DVT

* unilateral leg pain, calf tenderness on ambulation, swelling, warmth, redness, legs unequal size

s/s of pulmonary embolism

dyspnea, tachypnea, sudden chest pain, tachycardia, cardiac dysrrythmia, apprehension, hemoptysis. Death can result from cardiac failure and hypoxia.

prevention of thrombolitic disorders

early ambulation

management for SVT

nsaids (ibuprofen), graded ambulation, elastic compression stockings to support venous structures and prevent further stasis, local application of moist heat

management of DVT

\-same thing as management of svt (nsaids (ibuprofen), graded ambulation, elastic compression stockings to support venous structures and prevent further stasis, local application of moist heat )

\-Plus initial anticoagulant therapy (IV heparin)

after symptoms have decreased of thromboembolitic disorders

oral anticoagulants added

thromboembolitic disorders

\-inspection of affected area

\-Measure leg circumference \*\*

\-Palpate peripheral pulses

\-Monitor for signs of pulmonary embolism

\-Monitor lab values

\-Encourage position changes in bed

\-Teach to avoid prolonged compression of popliteal space, don’t rub affected area

\-Usually goes home on oral anticoagulants

\-Teaching to decrease chance of reoccurrence e.g. exercises,

keeping legs uncrossed etc...

uterine atony

failure of the uterus to contract

what is the leading cause of PPH

uterine atony

uterine atony is associated with

high multiparity, polyhydramnios, large fetus, multiple pregnancy, traumatic birth, oxytocin induction, precipitous birth, prolonged labour, magnesium sulphate

care related to PPH

* Examine all clots for signs of placental fragments or membranes
* May need to treat for shock: emergency situation - perfusion of organs may be severely


* compromised, death may occur
* Restore circulating blood volume
* Monitor P, BP
* Fluid or blood replacement therapy
* Oxygen
* Monitor blood work
* Assess S&S of anemia, fatigue, pallor, Hct level
* Monitor urinary output
* Encourage rest. Watch for dizziness
* Close assessment of fundus, lochia,

if necessary

* If oxytocin can’t control bleeding –count pads cytotec, hemabate

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* Non pharmacological – Bakri Balloon

is the period of time when you become pregnant and up to a year after giving birth.

perinatal

influencing factors for the development of attachment

Mutuality

Acquaintance phase

Claiming process

acquaintance phase

getting to know cues

claiming process

similarities with family

Attachment is strengthened by Communication between parent and infant:

Touch \n Eye to eye - en face

Voice \n Smell

what are some ways to help facilitate bonding

* Skin to skin contact


* Rooming in
* Open father visiting
* Teach parent(s) skills to care for newborn
* Reinforce positive parenting

behaviours

rubin 3 phases of maternal adjustment

\-taking in

\-taking hold

\-letting go

taking in

dependency phase

taking hold

becoming more independent. still needs reassurance

letting go

move forward as a new family unit

engrossment (how father feels toward new baby)

has been used to describe the powerful response fathers often feel toward their newborn, including his attraction to the infant, perception of the newborn as "perfect," extreme elation and heightened self-esteem.

what is the leading cause of death among new moms

suicide

postpartum blues

* Self-limited
* Affects 70% of women
* Symptoms peaks approximately 4 days after birth and decrease by 10 days to 2 weeks postpartum


* Nursing Interventions- include support system

postpartum depression

\-may last for weeks or months

\-can develop anything within the first year after childbirth

\-may be hormonal imbalance and

predisposition; Past personal or family history of

psychiatric disorders; Poor maternal health

risk factors for postpartum depression

low self-esteem, lack of social support, prenatal or depression, fatigue, child care stress

s&s of postpartum depression

inability to sleep, uncontrollable crying, fatigue, feelings of worthlessness, negative outlook on future, feelings of isolation, lack of concern for personal appearance, uncontrollable anxiety, irritability, obsessed thoughts of being a failure, anger, problems with maternal- infant interaction, feelings of being an inadequate mother

postpartum psychosis

* Most severe psychiatric problem related to pregnancy and childbirth
* Occurs in less than 2% of postpartum clients
* Approximately 1 in 1000 births (CMHA, 2012).
* Severe condition that often presents quickly between 48 hours and 2 weeks postpartum
* medical emergency

postpartum panic disorder

* Individuals with a panic disorder are struck with fears that they know are irrational and illogical however that cause them to drastically change their lives to avoid situations that they fear (CMHA, 2014)
* Involve full blown panic attacks and extreme anxiety during the postpartum period


* Signs and symptoms
* Treatment: cognitive and behavioural therapies,

medications, support to individual

**When palpating the fundus of a woman 18 hours after birth, the nurse notes that it is firm, two fingerbreadths above the umbilicus, and deviated to the left of midline. The nurse should: ?**

assist the woman to empty her bladder.

(The findings indicate a full bladder, which pushes the uterus up and to the right or left of midline. The recommended action would be to empty the bladder.)

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**The nurse examines a woman 1 hour after birth. The woman’s fundus is boggy, midline, and 1 cm below the umbilicus. Her lochial flow is profuse, with two plum-sized clots. The nurse’s initial action would be to: ?**

massage her fundus

**Excessive blood loss after childbirth can have several causes; however, the most common is:**

failure of the uterine muscle to contract firmly.

The uterus involutes rapidly after birth and returns to the true pelvis within ___ weeks and resumes normal size and position by _ weeks.

2\.

6\.

The rapid decrease in estrogen and progesterone levels after expulsion of the _______ is responsible for triggering many of the anatomical and physiological changes in the puerperium.

placenta

**The breasts of a bottle-feeding woman are engorged. The nurse should tell her to:**

wear a snug, supportive bra.

(A snug, supportive bra limits milk production and reduces discomfort by supporting the tender breasts and limiting their movement)