maternity chpt 12-14

physiologic changes in breasts

• after delivery, estrogen and progesterone decrease and prolactin increases

• prolacitn stims breast milk production

• hen infant suckles, the posterior pituitary releases oxytocin, resulting in the milk ejection reflex (let down reflex)

post partum assessment of breasts

• examine whether or not mother is breastfeeding

• observe size, symmetry, and shape

• assess for flat or retracted nipples

• assess for signs of nipple trauma if breastfeeding

• palpate for firmness or tenderness

expected findings of PP breast assessment

• breast fullness is normal immediately after delivery

• it is soft and nontender

• ~3rd PP day, both breastfeeding and nonbreastfeedign pts experience some degree of primary breast engorgement

  • incr vascular and lymphatic system of the breasts recedes milk production

• breasts become larger, firm, warm, and tender, she may feel throbbing pain in breasts

• primary engorgement subsides eithin 24-48 hrs

deviations from normal PP breast assessments

• signs of irritation and tissue breakdown are cracked, blistered, r reddened areas

• skin breakdown of nipples is often associated with an improper infant latch

• nipple soreness is a rimary reason that women stop breastfeeding, so this complaint should b addressed

• skin breakdown allows entery for bacteria

nursing action of breasts: for nonreastfeeding pt education

• avoid stimulating breast

• ice packs to breasts (lettuce cold)

• analgesics for pain management

• subsides within 48-72 hrs

• “how are you breastfeeding the baby”

nursing action of breasts: for breastfeeding pt education

• frequent feedings to empty the breatss and to prevent milk stasis

• warm compresses to breast and breast massage to facilitate the flow of milk before feeding sessions

• express milk by breast pump or manually if the infant is unable to nurse (i.e. preterm infant)

• ice packs after feedings to reduce inflammation and discomfort

• analgesics for pain man.

when does masitis occur

• incidence: occurs most often 3 months after birth, 2-10% of women are affected

etiology of mastitis/how is it caused

• caused by staphylococcus aureus

• engorgement and stasis of milk

• contrisction of breatss by a bra that is too tight

• fatigued mother or has health problems that lower immune system

assessment findings of mastitis

• breast tenderness or warmth to the touch

• generally feeling ill (malaise) or muscle ache

• breast swelling and hardness

• pain or a burning sensation continuously or while breastfeeding

• skin redness, often in a wedge shaped pattern

• fever of 101 or greater

med management of mastitis

• oral antibiotics x10-14 days

• culture expressed milk from affected breasted if infection does not resolve

• untreated mastitis may progress to abcess

pt teaching on risk reduction of mastitis

• complete emptying breast and good breastfeeding techniques

• postpartum nurse must teach breastfeeding techniques

• encouraged to avoid missed feedings

• wash hands before feeding

• decreased nipple irritation and tissue breakfwon

• use more than one breatsfeeding position

• air dry nipples after feeding

• feed on unaffected side first, then on affected so then you have lactation let down from affected side

physiologic changes in cardiovascular system

• average blood loss from vaginal birth: 200-500 mL

• increased flow of blood back to the heart

• decreased pressure from pregnant uterus on the bessels

• mobilization of excess extracellular fluid into the vascular compartment

• cardiac output is elevated for 24-48 hours after delivery and returns to prepregnant levels within 10 days

what is diuresis and diaphoresis

• increasd excretion of irome

• urinary output increased in pp period of up to 3,000 mL/day

  • nursing consideration

• diaphoresis (pofuse perspiration)

phys changes: cardiovascular - what are 2 hematologic system changes

• leukocytosis

• hemoglobin and hematocrit

what is leukocytosis

• incr. WBC as high as 30,000/mm3 during labor and immediately pp

• return to normal within 6 days after birth

what is hemoglobin and hematorcit and wy is it difficult to interpret

• decr in Hgb bc of blood loss

• low Hct due to plasma that dilutes the concentration of blood cells

• return to normal within 4-6 wks

phys changes: cardio - hypercoagulable state

• pt is still in a hypercoagulable state during the postpartum period

• new mothers are increased risk for thrombus formation

• elevations in clotting factors cause continued risk of thrombus formation

• hemostasis returns in 4-6 wks

pp assessment for cardiovascular

• q15 mins for first hour of delivery

• q30 mins for second hour of delivery

• q4 hrs for next 22 hrs

• every shift sfter the first 24 hours or as stated in hospital or unity protocols

expected findings of pp assessment cardio

• P& BP within normal ranges, after delivery systolic and diastolic BP may show a transient 5% elevation

• bradycardia may occur postdelivery and in the early PP period, and is considered normal

pp assessment of cardio, assess temp and prescence of chills: expected

• expected findings:

  • offered warm blanket and reassure it is normal

pp assessment of cardio, assess temp and prescence of chills: deviations from normal

• women with elevated temp should be eval. further for possible infection, and the physician or midwife needs to be notified

pp assessment for cardiovascular

• assess lower extremities for venous thrombosis

• assess calves and groin area for tenderness, edema, and sensation of warmth each shift

  • compare pulses in both extremiies

  • measure the calf width if thromboembolism is suspected

expected cardiovascular findings during PP assessment

• no tenderness or feelin of warmth

deviatons fro normal findings in cardiovascular PP assessment

• symptoms of deepvein thrombosis include:

  • muscle pain

  • tenderness

  • redness or incr. warmth to touch

  • palpatin of a hard, cord like vessel

  • swellin of veins

  • edema

  • decreased blood circulatin to the affeced area

complications of venous thromboembolic disease

• VTE a blood clot that starts in a vein; risk highest during pregnancy but extends though the 12th week pp

2 types of venous thromboembolic disease

• deep vein thrombosis - clot deep in vein, in the leg, sometimes in arm or other veins

• pulmonary embolism - DVT clot break free from a vein wall, travels to lungs, blocks blood supply

risk factors of venous thromboembolic disease unrelated to pregnancy

• personal history of VTE

• thrombophilia

• obesity

• cancer

• smoking

• immobility

• trauma

• infection

how does venous thromboembolic disease present in pregnancy

• 5x moe than nonpregnant women d/t:

  • venous stasis inlower extremiies

  • incr. blood volume

  • compression of inferior vena cava and pelvic veins with advancing gestation

nursing action to prevent thrombus formation

• decreased risk with early ambulation

• sequential compression device

• anti-embolism stockins

nursing care of thrombophlebitis (cardiovascular)

• apply supportive bandage or antiembolic stockings

• apply a warm pack to the affected area

• slightly elevated involved leg

• perform serial measurements of circumference of calves; a circumference difference of more than 2 cm is classified as leg swelling

• monitor vitals signs every 4 hours; there may be a slight increase in temperature

• heparin anticoagulation therapy may be ordered

physiologic: respiratory - how to assess

• Assess respiratory rate:

  • q15 mins for first hour

  • q30 mins for second hour

  • q4 hrs for the next 22 hours

  • every shift after the first 24 hours or as stated in hospital or unit protocols

• Assess breath sounds

who is at risik for pulmonary edema

• women who received oxytocin, large amounts of IV fluids, tocolytics such as magnesium, sulfate or terbutaline, had multiple birth, or PEC, or on bed rest

phys. changes in respiratory: expected findings

• the respiratory rate inthe postpartum perid is typically in the range of 12 to 20 breaths per minute

• the PaO2 should be 95% or higher

• breath sounds clear

physiologic changes in cervix

• dilated, edematous, and bruised

• small tears or lacerations may be present

• rapid healing takes place

physiologic changes in vagina

• greatly stretched

• walls appear edematous

• may have multiple small lacerations

• few vaginal rugae (folds) are present

  • rugae begin to reappear by 3-4 wks

  • vaginal epithelium restored 6-20 wks

• vaginal wall regains thickness

• dyspareunia (discomfort durin inercourse)

phys. changes in vagina: estrogen

• estrogen is key for vaginal walls to regain thickness

  • without estrogen, vagina becomes atrophic

  • estrogen is produced by ovaries and during lactation, decr. inestrogen contributes to vaginal dryness which may lead to dyspareunia

phys. changes in perineum

• pelvic floor muscle stretch and thin

• may be edematous and bruised

• laceration and episiotomy - episiotomy may not completely heal for another 6 months

phys changes of uterus: involution

• return to pre-pregnant state; usually takes 6-8 wks postpartum

phys. changes of uterus: afterpains

• caused by strong intermitent uterine contraction