PP et al

Postpartum period

§as all changes emotional and physical that take place in mother during the first year after delivery

puerperium period

begins after the delivery of the placenta and lasts approximately 6 weeks

fourth trimester

first 12 weeks after birth

Uterine Involution- 

the process of the uterus returning to its normal prepregnant size. First 12 hours, the fundus of the uterus is located at the level of the umbilicus.

What length per day does the uterus decend from the level of the umbilicus

1cm- one fingerbreadth

On what day is the fundus not palapted because it has decended into the true uterus?

Day 10

The vaginal discharge that occurs after birth and continues for approximately 4-8 weeks. This is when the endometrium becomes necrotic and is sloughed off.

Lochia

Color of lochia should be

Deep red. Each day, the amount of bleeding should be less and the color lighter and lighter

Why do women who have had c-section births tend to have less flow?

The uterine debris is removed manually

What are the 3 stages of lochia?

Lochia rubra, lochia serosa and lochia alba

Define lochia rubra

This the deep red mixture of mucus, tissue debris and blood for the first 3-4 days.

Lochia serosa

Its pinkish-brown and is expelled 3-10 days pp. It contained leukocytes, decidual tissue, RBC and serous fluid.

Creamy white or light brown and consists of leukocytes, decidual tissue and serous fluid(maternal uterine tissue). It occurs 10-14 days but can last 3-6 weeks

Lochia alba

Offensive lochia odor?

Infection such as endometritis

This is the primary mechanism preventing hemorrhage from the placental site. This is experienced by all women after birth and delivery of the placenta where the uterus begins to constrict and contract the vessels to impede blood flow.

Afterpains

Who experiences stronger than normal afterpains

multiparous women, women who receive oxytocin PP or other uterotonic medication.

Cervix

After a vaginal birth, it remains partly dilated, bruised and edematous. It returns to its prepregnant state by week 6. It does not return to its prepregnant state.

Vagina

Shortly after birth, its relaxed, has thin mucosa and few rugae. Returns prepregnant by 6-8 weeks but still remains larger than before.

Perineum

The perineum is often edematous and bruised for the first day or two after birth.

If the birth involved an episiotomy or laceration, complete healing may take as long as 4 to 6 months in the absence of complications at the site, such as hematoma or infection

Perineal lacerations may extend into the anus and cause considerable discomfort for the mother when she is attempting to defecate or ambulate. §The presence of swollen hemorrhoids may also heighten discomfort.

Blood volume

The decrease in blood volume reflects the birth-related blood loss (an average of 500 mL with a vaginal birth and 1,000 mL with a cesarean birth

Blood plasma volume is further reduced through diuresis

An acute decrease in hematocrit is not an expected finding and may indicate hemorrhage— Normal hematocrit -Adult females: 36% to 44%.

What indicates a decrease in cardiac output?

Bradycardia

What does tachycardia in pregnant women indicate?—above 100 bpm

Hypovolemia, dehydration or hemorrhage.

How would preeclampsia manifest?

A significant increase in BP accompanied by a headache.

What would be an indication of uterine hemorrhage?

Acute decreased blood pressure.

Coagulation

§Clotting factors that increase during pregnancy tend to remain elevated during the early postpartum period.

This hypercoagulable state places the woman at risk for thromboembolism (blood clots) in the lower extremities and the lungs

Diuresis

Over 4 weeks gradual return of bladder tone and normal size

Diuresis begins within 12 hours after childbirth and continues throughout the first week postpartum.

What may impede urination?

Perineal lacerations

Bruising and swelling of perineum and tissues surrounding meatus

Hematomas

Decreased bladder tone- regional anesthesia

Diminished sensation of bladder pressure

How does urinary retention and bladder distention cause PP hemorrhage?

By displacing the uterus from the midline to the right or left-This inhibits the uterus from contracting properly.

Common problem during pp period caused by fear of pain or damage to the perineum

constipation.

Name factors that cause decreased peristalsis? and what intervention

Analgesics

Surgery

Diminished inter-abdominal pressure

Low fiber diet

Insufficient fluid intake

Diminished muscle tone.

—Prescribe a stool softener

What musculoskeletal changes are associated with pregnancy?

Ligament laxity

weight gain

Change in the center of gravity

Revert back

What changes do women experience in the integumentary system as estrogen and progesterone decreased?

Linea nigra, melasma and dark pigments around nipples start to fade

Temporary hair loss

Stretch marks start to fade but not disappear

Lactation

§Breast milk typically appears within 4 to 5 days after childbirth.

What triggers the synthesis and secretion of milk after childbirth?

Prolactin from the anterior pituitary gland

What is the let down reflex

tingling sensation in both breasts §that occurs immediately before or during breastfeeding.

Breast Engorgement

distention and swelling of the breast tissue , causing tender, swollen, and painful breasts .

Engorgement can occur from infrequent feeding or ineffective emptying of the breasts

How do we treat breast engorgement

§heat or cold applications

§cabbage leaf compresses

§breast massage and milk expression

§breast pumping

§anti-inflammatory agents. Between feedings

§apply cold compresses after feedings to reduce swelling

§If a woman does not desire to breast-feed, what are some relief measures ?

§wearing a tight, supportive bra 24 hours daily

§applying ice to her breasts for approximately 15 to 20 minutes every other hour

§Avoid any stimulation to the breast

§Avoid exposing the breasts to warmth

For nonlactating women, menstruation may resume as early as

7 to 9 weeks after giving birth

What variables will allow the return of menses for lactating women?

Frequency and duration

During the PP period, Vietnamese women view it as

a cold state(Duong) and protect themselves with warmth—warm foods and showers

the close emotional attraction to a newborn by the parents that develops during the first 30 to 60 minutes after birth.

Bonding

Golden Hour

the first hour after birth is so important for skin-to-skin contact between mother and infant- temperature regulation

Mothers visually and physically “explore” their infants

the formation of strong affection between an infant and a significant other (mother, father, sibling, and caregiver).

attachment

attachment behaviors include

Seeking

attentiveness to the infant’s needs

staying close to, touching, kissing, cuddling and choosing face ptn while holding-feeding the baby

what are some factors hindering attachment

separation of infant from parents immediately after birth for long periods

Intensive care environment with restrictive policies

staff indifference or lack of support

How often should we perform PP assessment?

1st hour: every 15 minutes

2nd hour: every 30 minutes.

24 hours: every 4 hours

After 24 hours: every 8 hours

During each assessment what else are we assessing?

includes assessing the parents and other family members for attachment and bonding with the newborn.

When is the mother likely to hemorrhage?

the 1st 2-3 hours.

What is an early detector of complications?

Changes in vital signs

What are postpartum danger signs

fever that is greater than 100..4- 38C

Foul smelling lochia or an unexpected change in color or mount

Large blood clots or bleeding that saturates pad within an hour

Severe headache or blurred vision

Visual changes such as blurred vison or spots or headaches

Calf pain with dorsiflexion of the foot

Swelling, redness or discharge at episiotomy, epidural or abdominal sites

Dysuria, burning or incomplete emptying of the bladder

SOB or difficulty breathing without exertion

Depression or extreme mood swings.

what can a boggy uterus indicate?

Clog- filling up the uterus. We should’nt have non-existent lochia

What can cause an increase in temperatures?

when the milk drops

Laboring for a long time

pushed for a long time

Order a CBC and urine

what is considered normal pulse rate during the first week after birth?

pulses of 60-80 per minute at rest

Tachycardia in PP women can be an indication of

anxiety

fatigue

pain

excessive blood loss or delayed hemorrhage

infection

underlying cardiac problems

A pulse rate higher than——— warrants further investigations

100BPM

In a PP woman what can change the respiratory rate?

Pulmonary edema

atelectasis-epidural anesthesia

Pulmonary embolism

What does an increase and decrease in blood pressure indicate after PP?

An increase would indicate gestational hypertension

Decrease would indicate shock or orthostatic hypotension, dehydration or a side effect of epidural anesthesia.

what nursing intervention should nurses do for PP pain

Provide comfort measures

include perineal care

a clean gown

mouth care

providing warm blankets

ensuring adequate fluid intake to facilitate healing

repositioning frequently

encouraging rest between assessments

Physical examination of the postpartum woman focuses on assessing the

breasts, uterus, bladder, bowels, lochia, episiotomy/perineum and epidural site, and extremities.

what does BUBBLEES stand for?

B- Breast

U- Uterus

B- Bladder

B- Bowel

L- Lochia

E-- Episiotomy

E-Emotional status

S- Swelling

Examination of Breasts

§Inspect the breasts for size, contour, asymmetry, engorgement, or erythema- do your breast hurt, are they painful- mastitis, engorgement, touch the top of breast,

§Check the nipples for cracks, redness, fissures, or bleeding, and note whether they are erect, flat, or inverted.

§Cracked, blistered, fissured, bruised, or bleeding nipples in the breast-feeding woman are generally indications that the baby is improperly positioned on the breast.

§Palpate the breasts lightly to ascertain if they are soft, filling, or engorged, and document your findings.

Examination of Uterus

§Assess the fundus (top portion of the uterus) to determine the degree of uterine involution- pregnant to pre-pregnant state.

§Using a two-handed approach with the woman in the supine position with her knees flexed slightly and the bed in a flat position or as low as possible

§Palpate the abdomen gently, feeling for the top of the uterus while the other hand is placed on the lower segment of the uterus to stabilize it

Once the fundus is located, place your index finger on the fundus and count the number of fingerbreadths between the fundus and the umbilicus

Documentation of Fundus

§If the fundus is above the Umbilicus it will be documented by the number of fingerbreadths it is located at level of, below or above fundus.

§A fundus at the umbilicus will be documented as FF@U

§A fundus 1 below the Umbilicus will be documented as FF @ U/1

§A fundus 1 above the Umbilicus will be documented as FF @ 1/U

Examination of Uterus

§The fundus should be midline and should feel firm.

§After birth, the fundus is usually at the level of the umbilicus

§If the fundus is above the umbilicus and to the right or left, ask the woman to empty her bladder and reassess the uterus again- straight cath or foley

§A boggy or relaxed uterus is a sign of uterine atony- bleed

What can cause a boggy uterus?

Stretched out uterus—above the umbilicus- twins, large baby, polyhydramnios

if the fundus is above the umbilicus and to the right or left, what should the nurse do?

Ask the woman to empty her bladder and reassess again

What is uterine atony and wat can cause it?

This is a boggy or relaxed uterus as a result of Result of bladder distention, retained placental fragments, prolonged labor, precipitous labor, or overdistended uterus (LGA or Multiple fetuses).

What can cause a PP hemorrhage?

an overdistended bladder that is preventing the uterine muscles from contracting

What is Postpartum urinary retention?

inability to empty the bladder withn 6 hours after a vaginal birth- use a straight cath

Examination of Bowels

§Inspect the woman’s abdomen for distention, auscultate for bowel sounds in all four quadrants prior to palpating the uterine fundus, and palpate for tenderness.

§The abdomen typically is soft, nontender, and nondistended. Bowel sounds are present in all four quadrants.

§Ask the woman if she has had a bowel movement since giving birth.

§Spontaneous bowel movements may not occur for 1 to 3 days

§Normal assessment findings are active bowel sounds, passing gas, and a nondistended abdomen.

What must findings about lochia must the nurse report?

Heavy bright red lochia

Lochia with tissue fragments

Foul smelling lochia

What is the first step to take aftre excessive bleeding occurs

Massage the boggy fundus until it is firm to reduce the amount of bleeding

What practices must the woman know about lochia?

She must notify the HCP if lochia rubra returns after serosa and alba

The woman must have frequent changing of her pad- every 4 hours

Rinse the perineal area with a peribottle after pee and poop

Wipe front to back

Wash hands before and after changing pads

Amount of lochia

§Scant: a 1- to 2-in lochia stain on the perineal pad

§Light: an approximately 4-in stain

§Moderate: a 4- to 6-in stain

§Heavy: a pad is saturated within 1 hour after changing

what may indicate an infection of the episiotomy site?

Redness

swelling

increasing discomfort

purulent drainage

Side effects of an epidural?

Itching

nausea

vomiting

Urinary retention

Due to hypercoagulation, the woman is at an increased risk for? And what do we use to assess?

VTE and DVT. A duplex ultrasound

What signs and symptoms would the woman present with after a DVT has progressed to a PE

Hypotension

syncope

dyspnea

chest pain

What do ice packs help with at the site of an episiotomy or laceration?

minimizing edema

inflammation

decrease capillary permeability

reduces nerve conduction to the site

What is a sitz bath?

room temperature water may be prescribed and substituted for the ice pack to reduce local swelling and promote comfort for an episiotomy, perineal trauma, or inflamed hemorrhoids.

what are Nonpharmacologic measures to reduce hemorrhoid discomfort as well as perineal discomfort

§include ice packs, sitz baths, use of donut hole to for positioning in semi or high fowlers and application of cool witch hazel pads.

Pharmacologic methods used to reduce hemorrhoid pain

local anesthetics (dibucaine)

steroids (hydrocortisone acetate—episiotomy or repair—but too much can break down the skin).

What types of analgesics are prescibed for pain?

§Analgesics such as acetaminophen and oral nonsteroidal antiinflammatory drugs (NSAIDs) such as ibuprofen or naproxen are prescribed to relieve mild postpartum discomfort.

§For moderate to severe pain, a narcotic analgesic such as codeine or oxycodone in conjunction with aspirin or acetaminophen may be prescribed.

How do we assist PP women with bowel elimination?

A daily stool softener, such as docusate

Ambulating and increasing fluid

fiber intake

Encouraging the use of the side-lying position,

proper toileting habits

assuming positions that minimize putting pressure on the hemorrhoids

not straining during defecation will help reduce discomfort- get them off their bottoms all the time.

What helps bladder control, urine flow and pelvic muscle strengthening?

Kegel floor exercises.

What are some self-care measures to promote healing and prevent infection?

§Frequently change perineal pads, applying and removing them from front to back to prevent spreading contamination from the rectal area to the genital area.

§Avoid using tampons after giving birth to decrease the risk of infection.

§Shower once or twice daily using a mild soap. Avoid using soap on nipples.- drying effect

§Use the peribottle filled with warm water after urinating and before applying a new perineal pad.

§Avoid tub baths with soap for 4 to 6 weeks.

§Wash your hands before and after performing perineal care.

§Showing patient how to rinse her perineum with the peribottle after she voids or defecates.

§Instruct after voiding gently wipe from front to back and washing her hands thoroughly before and after perineal care.

§For hemorrhoids, have the client apply witch hazel-soaked pads, ice packs to relieve swelling, or hemorrhoidal cream or ointment if ordered.

What criteria must the woman meet before being discharged?

§hospital stay be at least 24 hours after birth.

§Mother is afebrile and vital signs are within normal range.100.4

§Lochia is an appropriate amount and color for the stage of recovery.

§Hemoglobin-12.1 to 15.1 g/dL and hematocrit-36-44 values are within normal range.

§Uterine fundus is firm; urinary output is adequate.

§ABO blood groups and RhD status are known and if indicated, anti-D immunoglobulin has been administered.

§Surgical wounds are healing, and no signs of infection are present.

§Mother is able to ambulate without difficulty.

§Food and fluids are taken without difficulty.

§Self-care and infant care are understood and demonstrated.

§Family or other support system is available to care for both.

§Mother is aware of possible complications

§Ensure Follow-up appointment is scheduled

What are the 5 Ts? and what do they indicate?

They are causes of PP hemorrhage

§Tone: uterine atony (most common cause) –boggy- c-sections because of a spinal and bypassing the normal way of delivery—Uterus is shocked and can't clamp down as usual

§Tissue: retained placental fragments (always check placenta)-mother wont stop bleeding until tissue is removed

§Trauma: lacerations, hematoma-losing blood, inversion- uterus folding into itself, rupture

§Thrombin: coagulopathy issues (hemophiliac, DIC—clotting factors not working secondary to sth, bleeding from everywhere including eyes)

§Traction: too much pulling on umbilical cord- good gentle pulling

PP Hemorrhage Risk Factors

§prolonged labor

§Precipitous labor – labor within 3 hours- uterus is shocked and wont clamp down

§Retained placental fragments

§Placenta previa- placenta covers cervix or placental abruption—placenta tears from the uterine wall.

§Operative procedures (cesarean, forceps delivery, vacuum extraction)

§overdistention of uterine muscles (multiple gestation, polyhydramnios, or a large fetus)

§full bladder (which displaces the uterus and interferes with contractions)

§anesthesia (which relaxes uterine muscles--)

§close childbirth spacing (frequent and repeated distention decreases tone and causes muscular relaxation).

Uteretonic medications

§Pitocin/ oxytocin—first line of defense—never given undiluted as a bolus injection intravenously, can be given IM

§Cytotec—Misoprostol—do not give if woman has active cardiovascular disease, pulmonary or hepatic disease- rectally or oral cytotec

§Prostin E2—Dinoprostone—contraindicated in active cardiac, pulmonary, renal, or hepatic disease

§Methergine—Methylergonovine maleate-–if the woman is hypertensive, do not administer

§Hemabate—Prostaglandin/ carboprost—contraindicated with asthma due to risk of bronchial spasm (causes diarrhea)

What are Puerperal infections

complications that can occur up to 28 days following childbirth.

What is A major complication of puerperal infections?

septicemia. Any fever higher than 100.4 F

Name types of PP infections

§Endometritis is a uterine infection that typically develops within 2 to 4 days postpartum to as late as 6 weeks.

§Wound infection include cesarean surgical incisions, the episiotomy site in the perineum, and genital tract lacerations

§UTIs are most commonly caused by invasive manipulation of the urethra (e.g., urinary catheterization), frequent vaginal examinations, and genital trauma increase the likelihood of a UTI.  Possible progression to pyelonephritis.

§Mastitis is defined as inflammation of the mammary gland, a common problem that may occur within the first 2 days to 2 weeks postpartum. Risk factors associated with mastitis include stasis of milk due to infrequent, inconsistent breast-feeding, previous episodes of mastitis, and nipple trauma.

What are expected findings in endometriosis and their interventions?

§Pelvic Pain

§Chills,

§Uterine tenderness and enlargement- swelling

§Dark profuse lochia

§Malodorous lochia- pungent

§Fever greater than 100.4 F or 38 C

§Tachycardia

Assess fundal height and lochia

Assess Pain

Administer antibiotics therapy per physician orders according to hospital protocol

Obtain frequent vital signs

Obtain blood, intracervical, and intrauterine cultures to reveal offending organisms

Expected findings in wound infection and their interventions?

Wound warmth

Erythema

Tenderness

Edema

Seropurulent drainage

Wound dehiscence

Temperature greater than 100.4 F or 38 C

Use an aseptic technique when inspecting and assessing patient

Perform frequent hand hygiene

Obtain frequent vital signs

Assess pain

Inspect incisions (episiotomy and cesarean) and lacerations

Obtain frequent vital signs

Blood and would cultures to reveal offending organisms

Administer antibiotics therapy per physician orders according to hospital protocol

Clean and dry

expected findings in UTI and their interventions?

§Reports of urgency, frequency, dysuria, and discomfort in the pelvic area

§Fever greater than 100.4 F or 38 C

§Cloudy, blood-tinged, malodorous urine

§Pain at the costovertebral angle (pyelonephritis)

Obtain frequent vital signs

Blood and urinary bacterial cultures to reveal offending organisms

Administer antibiotics therapy per physician orders according to hospital protocol

Expected findings in mastitis and their interventions?

§Enlarged tender axillary lymph nodes- affected breast side

§Area of breast that can be red, swollen, warm and tender

§Educate patient importance of completely emptying breast (pumping after feedings) to prevent milk stasis which is a medium for bacterial growth

§Warm compresses to breast before feedings and ice packs after feedings.

§Administer antibiotics therapy per physician orders according to hospital protocol

§Provide pain medication as ordered

What factors increases the risk of PP complications?

Operative pprocedures- c-section, vaccum extraction, forceps

History of diabetes—gestational diabetes

Prolonged labor- more than 24 hrs

Indwelling catheter

Anemia- Hemoglobin of less than 10.5

Multiple vaginal exams during labor

Prolonged rapture of membranes—more than 24 ours

Manual extraction of placents

Compromised immune system—HIV positive