unit 5 postpartum

§The Postpartum period can be defined as all emotional and physical changes in the mother during the first year after delivery.

Postpartum period

The puerperium period begins after the delivery of the placenta and lasts approximately 6 weeks. This is considered:

considered the most critical time for the baby and baby

“Fourth trimester” is the _____ after birth.

first 12 weeks

the process of the uterus returning to its normal prepregnant size is called the ____.

uterine involution

First 12 hours postpartum, the fundus of the uterus is located at the _____.

level of the umbilicus.

Uterus descends from the level of the umbilicus at a rate of 1 cm (one fingerbreadth) per day. By ____, the fundus usually cannot be palpated because it has descended into the true pelvis.

day 10

What is the vaginal discharge that occurs after birth and continues for approximately 4 to 8 weeks?

lochia

What color is the lochia immediately following childbirth?

deep red (rubra)

A nurse must educate a patient during the post-partum period to notify the HCP if she experiences what type of discharge?

lochia that was pink then suddenly turns a deep red, accompanied by blood clots

§Lochia rubra is a deep-red mixture of mucus, tissue debris, and blood that occurs for the_____.

first 3 to 4 days after birth.

Lochia serosa is a pinkish brown and is _____. Lochia serosa primarily contains leukocytes, decidual tissue, red blood cells, and serous fluid.

expelled 3 to 10 days postpartum.

Lochia alba is a creamy white or light brown and consists of leukocytes, decidual tissue, and serous fluid (maternal uterine tissue). It occurs from _____.

days 10 to 14 but can last 3 to 6 weeks

Lochia at any stage should have a fleshy smell; an offensive odor usually indicates an infection, such as endometritis. (true/false)

true; notify HCP if a foul odor discharge occurs

Immediately after birth and delivery of the placenta, the uterus begins to contract to constrict the vessels and impede blood flow; The primary purpose of this is to what?

primary mechanism preventing hemorrhage from the placental site

All women experience afterpains, more acute in_____ due to repeated stretching of the uterine muscles and _____ due to the release of oxytocin which causes uterine contractions.

multiparous; breast-feeding women

The cervix typically returns to its prepregnant state by ____of the postpartum period.

week 6

§Immediately after a vaginal birth, the cervix extends into the vagina and remains partly___, ___, ___.

dilated, bruised, and edematous.

In the vagina, the mucosa ___ and the rugae will return in approximately in ____.

thickens; 3 weeks

The ___ is often edematous and bruised for the first day or two after birth (or even several days).

perineum

Perineal lacerations may extend into the anus and cause considerable discomfort for the mother when she is attempting to __ or ___.

defecate or ambulate

The decrease in blood volume reflects the birth-related blood loss with an average of ____ with a vaginal birth and ____with a cesarean birth).

500 mL; 1000ml

An acute decrease in hematocrit is not an expected finding and may indicate____.

hemorrhage

How is the pulse and blood pressure affected post-partum?

decrease in cardiac output (bradycardia)

decrease in blood pressure

Hypercoagulable state places the woman at risk for _____ in the lower extremities and the lungs.

thromboembolism (blood clots)

What patients are at high risk for DVTs?

morbidly obese patients

c-section (surgery patients)

smokers

immobility (post delivery)

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

Diuresis

What are factors that impede women from adequate urination (diuresis) following birth?

Perineal lacerations

Generalized swelling and bruising of the perineum

Hematomas (close off the meatus)

Decreased bladder tone due to anesthesia

Diminished sensation due to epidural

It is important to keep the bladder full because it can cause the fundus (uterus) to do what?

move above the umbilicus

Decreased peristalsis (constipation) occurs in response to analgesics, surgery, diminished intra-abdominal pressure, a low-fiber diet, insufficient fluid intake, and diminished muscle tone during the postpartum period. What can the nurse give/do to alleviate constipation?

stool softener (Colace/doculace). ambulation, high fiber diet, increase fluids, and PASS GAS!!!

Musculoskeletal changes associated with pregnancy, such as increased ligament laxity, weight gain, change in the center of gravity, and carpal tunnel syndrome, ____ during the postpartum period.

revert back

Breast milk typically appears within ____ after childbirth.

4 to 5 days (before that is colostrum which is the liquid gold)

The nurse educates the patient that they will get a full sensation in the breast, along with a shock on tender breasts when their body is beginning to ____. Mom’s temperature may elevate but should not be higher than 100.4F

lactate (breast feed)

A mother complains of enlarged breasts that are painful, swollen, tender, and distended. What following question does the nurse ask?

‘When was the last time you breastfed?”

What intervention has to be done in order to alleviate engorgement?

Encourage the patient to empty the breast (feed the baby)

What are the treatments for breast engorgement?

Heat before feeds, cold after feeds

Cabbage leaf compresses

Breast massage/milk expression by self-express/pumping

Anti-inflammatory agents

If a woman does not desire to breast-feed, some relief measures tp suppress lactation include:

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 during intercourse

Avoid exposing the breasts to warmth during showers

For nonlactating women, menstruation may resume as early as______ after birth.

7 to 9 weeks

Many cultures involve the balance of hot and cold and confinement after childbirth. (Yin and Yang) .Vietnamese women view the postpartum period as a cold state (duong) and protect themselves with warmth, such as ___, and ___.

warm foods, warm showers

Bonding is the close emotional attraction to a newborn by the parents that develops during the _____ after birth.

first 30 to 60 minutes

______ (or the first hour after birth) is so important for skin-to-skin contact between mother and infant. Mothers visually and physically “explore” their infants.

Golden hour

During golden hour, the nurse can postpone interventions. What is the rationale?

leaving the baby on the mother’s chest is vital to regulate the baby’s temperature and to encourage bonding—vitals, weight, etc can wait

A mother is non-attentive to her baby’s needs. The baby is crying and the mother is not interested in cuddling the baby to soothe him/her. The mother states “it needs to be quiet so I can sleep” What does the nurse suspect?

the parent is affecting the bonding and attachment

Delivery time of 10:00 for a Mexican mother. How often does the nurse need to do vital signs, a physical and psychosocial assessment?

during the 1st hour, every 15 minutes

during the 2nd hour, every 30 minutes

during the 24 hours, every 4 hours

after 24 hours, every 8 hours

The nurse is taking vitals after a delivery. The vital signs are: Temperature- 101.2OF, HR- 120, RR- 18. What does the nurse suspect?

infection

What labs does the nurse anticipate when a patient has abnormal vitals signs, specifically an elevated temperature?

urine samples, WBC, cultures, or CBC

Any change in respiratory rate out of the normal range might indicate ____, ____, or ____.

pulmonary edema, atelectasis (a side effect of epidural anesthesia), or pulmonary embolism

The nurse assesses breath sounds in all lung fields. The nurse finishes and the lungs are not clear upon auscultation. What does the nurse do?

report to HCP because atelectasis is suspected

A mother complains of a pain scale of 8 out of 10. What comfort measures can the nurse implement?

perineal care, a clean gown, mouth care

providing warm blankets

ensuring adequate fluid intake to facilitate healing

repositioning frequently

encouraging rest between assessments

During post-partum, what is the acronym for all the assessments that need to be done?

Breast

Uterus

Bladder

Bowel

Lochia

Episiotomy

Emotional Status

Swelling

Cracked, blistered, fissured, bruised, or bleeding nipples in the breast-feeding woman are generally indications that the baby is improperly positioned on the breast. What interventions does the nurse need to implement to avoid this?

Educate on proper breastfeeding techniques and frequent assessment of breasts

How is a proper palpation to examination the uterus done?

Two hands must be used to palpate the abdomen gently, feeling the top of the uterus while placing a hand in the lower segment to stabilize it and then counting the number of fingerbreadths

If the fundus is above the umbilicus and to the right or left, ask the patient to do what?

empty her bladder and reassess the uterus again (may need assistance, straight cath, indwelling cath, may be needed).

A boggy or relaxed uterus is a sign of uterine atony (no tone). This is a huge risk for _____.

post-partum hemorrhage

What questions does the nurse need to ask a patient when examination lochia?

“When was the last time you changed your pad and how saturated was it and/or did it include any clots?”

A nurse needs to examine the amount and color of lochia during post-partum. The patient is laying in bed. How does the nurse complete the assessment?

Check under the woman by turning her to either side to make sure additional blood is not hidden and not absorbed on her perineal pad.

A patient states “I have had to change my pad twice in the past two hours.” What interventions does the nurse need to implement immediately?

The patient is bleeding way too much so the nurse needs to massage the fundus until the uterus is no longer boggy. to reduce the flow of blood.

When is it normal to expect an increase in lochia?

lochia increases when the woman gets out of bed & during breast-feedings due to oxytocin release

What abnormal findings regarding lochia does the nurse need to report?

heavy, bright red lochia with large tissue fragments or a foul odor

What patient education is important for hygiene care of the perineum when lochia is present?

Frequent pad changes (every 4 hours)

Continued use of peribottle to rinse perineal area.

Hand hygiene before and after pad changes.

____ amount is a 1- to 2-in lochia stain on the perineal pad

Scant

_____ amount is approximately 4-in stain on pad.

Light

____ amount is about a 4- to 6-in stain on pad.

Moderate

_____ amount on a pad is saturated within 1 hour after changing.

Heavy

Large areas of swollen, bluish skin with complaints of severe pain in the perineal area with no relief from pain medications indicate:

pelvic or vulvar hematomas.

Redness, swelling, increasing discomfort, or purulent drainage may indicate infection in what area?

perineum

When anesthesia removes epidural catheter, you need to observe and document what?

the blue tip on the end is intact with no irritation at the site

With DVT may report lower extremity tightness or aching when ambulating, edema in the affected leg, warmth, and tenderness in the affected extremity. How can a diagnosis of a DVT be made?

The nurse needs to notify HCP to order a duplex ultrasound (2D ultrasound & doppler ultrasound).

§When DVT progresses to PE, it may do so without any signs or symptoms until the woman presents with ___, ___, ___, and/or ____.

hypotension, syncope, dyspnea and/or chest pain.

_____ is commonly the first measure used after a vaginal birth to relieve perineal discomfort from edema, an episiotomy, or a laceration.

An ice pack (to minimize edema, inflammation, reduce nerve conduction, and decrease capillary permeability)

The_____ is a plastic squeeze bottle filled with warm tap water that is sprayed over the perineal area after each voiding and before applying a new perineal pad.

peri bottle

Reinforce education to rinse with peri bottle after each time she changes her___, ___, or ____ making sure that she understands to direct the flow of water from front to back.

pad, voids, or defecates

After 24 hours, the nurse can expect the HCP to prescribe what to reduce local swelling and promote comfort for an episiotomy, perineal trauma, or inflamed hemorrhoids?

sitz bath (heat)

Nonpharmacologic measures to reduce hemorrhoid discomfort as well as perineal discomfort include:

ice packs

ice sitz baths

use of donut hole to for positioning in semi or high fowlers

application of cool witch hazel pads.

Pharmacologic methods used to reduce hemorrhoid pain include local anesthetics (such as ___) and steroids (such as ___).

dibucaine or hydrocortisone acetate

Analgesics such as acetaminophen and oral nonsteroidal anti-inflammatory drugs (NSAIDs) such as___ or ___ are prescribed to relieve mild postpartum discomfort.

ibuprofen or naproxen

How can a nurse assist with elimination/bowel?

daily stool softener (Docusate)

early ambulation

increase fluids & fiber

encourage side-lying position

discourage straining and sitting on bottom if hemorrhoids

How often should pelvic floor training/Kegel’s exercise be done to help the pelvic muscles?

10 exercises 3x a day

What must be done before Kegel’s exercises?

empty the bladder

Important to instruct woman and partner that there be nothing in the vagina until their follow-up appointment with their health care provider. (TRUE/FALSE)

true; the nurse must wait until 6 week follow up to continue sex

PPH is defined as a______ with signs and symptoms of hypovolemia within 24 hours of the birth process, regardless of the route of delivery

cumulative blood loss greater than 1,000 mL

A helpful way to remember the causes of postpartum hemorrhage is by using the five Ts:

Tone: uterine atony (most common cause)

Tissue: retained placental fragments (always check placenta)

Trauma: lacerations, hematoma, inversion, rupture

Thrombin: coagulopathy issues (hemophiliac, DIC)

Traction: too much pulling on umbilical cord

Prompt action is required for any recognized PPH including:

1.immediate fundal massage (keep close eye on BP & HR)- DO NOT STOP RUBBING!!!

2.Notify physician

3.intravenous fluid resuscitation (IV fluids)

4.administration of uterotonic medications

5.Prepare for possible blood transfusion (secondary IV, Stat CBC)

What uterus finding is abnormal?

a boggy uterus (meaning it is not felt, just an empty cavity)

What is the first line of therapy to cause or increase the frequency and intensity of uterine contractions?

Oxytocin (Pitocin)

Never give Oxytocin undiluted as _____, can be given IM.

a bolus injection intravenously

NEVER give ____ if the woman is hypertensive as an uterotonic medication.

methergine

Risk factors associated with mastitis include:

stasis of milk due to infrequent, inconsistent breast-feeding

previous episodes of mastitis

nipple trauma

What expected findings are associated with an endometritis infection?

The patient will complain of intense pelvic pain. The uterus will be enlarged and tender and have dark profused/maladorous lochia. The vitals signs will have an elevated temp, elevated HR following with chills.

Nursing care for wound infections include:

Inspect incisions (episiotomy and cesarean) and lacerations as perform hygiene on lacerations to keep it clean and dry.

_____ has expected findings of enlarged lymph axillary lymph nodes with the affected breast being red, swollen, warm and tender.

Mastitis

How is mastitis cared for?

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

§Unlike the postpartum blues, women with PPD feel worse over time, and changes in mood and behavior do not go away on their own. Women should be screened for postpartum depression if postpartum blues do not resolve within how long after giving birth?

2 weeks

______, an emergency psychiatric condition, can result in a significantly increased risk for suicide and infanticide. Women cannot be left alone with their infants if this occurs.

Postpartum psychosis