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What are the physiological changes that a postpartum patient goes through?
uterine involution (uterus returns back to normal)
lochia flow
cervical involution
decrease in vaginal distention
alteration in ovarian function & menstruation
cardiovascular, urinary tract, breast & GI tract changes
What are the greatest risks during the postpartum period for the patient?
hemorrhage
shock
infection (especially through the cervix)
What’s important to remember about oxytocin and its purpose?
oxytocin, a hormone released from the pituitary gland, coordinates and strengthens uterine contractions.
breastfeeding stimulates the release of oxytocin from the pituitary gland.
What hormones are decreased and what happens after they are decreased in postpartum patients?
Estrogen is decreased: diminishes vaginal lubrication causing local dryness and intercourse discomfort until the ovarian function returns
Placental enzyme insulinase is decreased: reverses Gestational Diabetes
HCG levels disappear from blood quickly
In lactating clients, why do blood lactic levels remain elevated and how long is postpartum ovulation suppressed?
the infants suck is believed to affect prolactin levels
length of time to the first postpartum ovulation is approximately 6 months
What occurs in non-lactating clients?
reaches pre pregnant level by 3 weeks postpartum
ovulation occurs 7-9 weeks after birth
menses resumes by 12 weeks postpartum
What’s included in a focused physical assessments? (BUBBLE)
B: Breasts
U: Uterus (fundal height, uterine placement, and consistency)
B: Bowel and GI function
B: Bladder function
L: Lochia (color, odor, consistency, and amount [COCA])
E: Epiosotomy (edema, ecchymosis [bruising], approximation)
Vital signs (pain assessment)
teaching needs
How rapidly does the uterus decrease in size?
approximately 1,000 g at the end of the third stage of labor to 60-80 g at 6 weeks postpartum with the fundal height steadily descending into the pelvis approximately one fingerbreadth (1 cm) per day
How often should the fundus descend?
every 24 hours, approximately 1-2 cm
should be halfway between the symphysis pubis and the umbilicus by 6 days postpartum
after 2 weeeks, uterus should lie within the true pelvis and should not be palpable
What should be assessed at least every 8 hours after the recovery period has ended?
fundal height
uterine placement
uterine consistency
What could be the cause of the fundus not being midline and what should be done to fix it?
full bladder
have patient empty the bladder
When assessing the fundus, the nurse notices that it is boggy. What nursing intervention should be done to help firm it?
Lightly massage the fundus in a circular motion
How does the nurse document the position and location of the uterus?
by the number of fingerbreadths (cm)
if above the umbilicus, document as +1, U+1, 1/U
if below the umbilicus, document as -1, U-1, U/1
if at the umbilicus, document as U/U
What is the purpose of oxytocics?
to promote uterine contractions and to prevent hemorrhage
Which oxytocics are most commonly used?
oxytocin
methylergonovine
carboprost
misoprostol (prostaglandin)
What side effect can oxytocin and misoprostol have on a postpartum patient?
can cause hypotension
What side effects can methylergonovine, ergonovine, and carbopost have on a postpartum patient and what's important to remember?
can cause hypertension
do not give to preeclampsia, severe preeclampsia, or eclampsia patients
What is the least invasive method of promoting uterine contractions and preventing hemorrhage?
encourage emptying of the bladder to prevent uterine displacement and atony (lack of normal muscle tone)
What is lochia?
post-birth uterine discharge that contains blood, mucus, and uterine tissue
What are the three stages of lochia?
Lochia Rubra
Lochia Serosa
Lochia Alba
What is seen with lochia rubra?
Dark red color (ruby red rubra), bloody consistency, fleshy odor
can contain small clots
lasts 1-3 days after birth
What is seen with Lochia Serosa?
pinkish brown color and serosanguineous (watery) consistency
can contain small clots and leukocytes
lasts approximately day 4 tp day 10 after birth
What is seen with Lochia Alba?
yellowish white (alba) creamy color, fleshy odor
can consist of mucus and leukocytes
lasts approximately day 10 up to 6 weeks postpartum
What is considered excessive blood loss when assessing lochia amount?
one pad saturated in 15 minutes or less or pooling of blood under buttocks
How often should the lochia be assessed?
at least every 15 minutes for first hour of bleeding
every 1 hour for next 4 hours
then every 4-8 hours
What’s a normal finding after massaging the uterus or ambulating?
a gush of lochia with the expression of clots and dark blood that has pooled in the vagina but should soon decrease back to a trickle of bright red lochia.
What are manifestations of abnormal lochia?
blood clots larger than 50 cent coin
numerous large clots and excessive blood loss (hemorrhage)
foul odor (infection)
persistent heavy lochia rubra beyond day 2 (placental fragments)
What client education should be given to a patient in regards to perineal care?
change pads frequently (every 2-3 hours)
perform hand hygiene after peri care & changing of pads
do not use tampons due to increased risk of infection
What physical changes occur to the cervix postpartum?
2-3 days after, it shortens, regains its form, and becomes firm with cervical outlet gradually closing
external outlet of cervix will no longer have round-dimple shape and will have a slit-like appearance
What physical changes occur to the vagina postpartum?
muscle tone is never restored completely
breastfeeding increases the incidence of vaginal dryness and atrophy
What physical changes occur to the perineum?
hematomas or hemorrhoids can be present (evaluate)
When does healing normally occurs for the cervix, vagina, and perineum?
initial healing occurs in 2-3 weeks and complete occurs within 4-6 months
What comfort measures can be done for perineal tenderness, lacerations, and episiotomy?
apply ice/cold packs to the perineum for the first 24 hours to reduce edema and provide anesthetic effect (do not apply directly)
heat therapy (hot packs), moist heat, and sits baths can be used to increase circulation and promote healing and comfort
encourage the sitz baths at a hot or cool temperature for at least 20 minutes for at least twice a day
apply topical anesthetic (benzocaine spray) to the clients perineal area as needed or witch hazel compresses or hemorrhoidal creams to the rectal area for hemorrhoids
What client education should be given in regards to perineal care?
wash both hands thoroughly before and after voiding
What are the physical changes of the breasts?
secretion of colostrum which occurs during pregnancy & 2-3 days immediately after birth
milk is produced about 72-96 hours after the birth
What education should be made about colostrum?
colostrum (early milk) transitions to mature milk about 72-96 hours after birth (milk coming in)
What is engorgement and what does it look like?
engorgement (fullness) of the breast tissue is a result of lymphatic circulation, milk production, and temporary vein congestion
breast will aparea tight, tender, warm, and full
What should the nurse inform the client about breast engorgement?
non breastfeeding client: this will resolve on its own; support bras, ice pack, birth control, or cabbage leaves can be applied to help resolve
breastfeeding clients: breast care and frequent feedings will help prevent or manage engorgements
What should the nurse observe for/assess of the breast?
erythema (redness)
breast tenderness
cracked nipples
indications of mastitis (infection of milk duct with flu-like symptoms)
What patient-centered care should be done for breastfeeding patients?
promote early breastfeeding within the first 1-2 hrs after birth
encourage early demand feeding (feeding only when baby is hungry) for client who chooses to breastfeed
this will stimulate production of natural oxytocin and help prevent uterine hemorrhage