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57 Cards in this Set
- Front
- Back
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Changes in the Uterus
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• Involution-The return to pre-pregnancy state.
– The uterus contracts to decrease in size and compress vessels, which decreases the uterine bleeding. |
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Involution
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• Begins immediately after expulsion of the placenta.
• 1-2 hours after the birth, the fundus is between the umbilicus and the symphysis pubis. • 6-12 hours after birth, the fundus is usually at the level of the umbilicus • Fundus descends 1-2 cm every 24 hours. • By 6 weeks postpartum, the uterus has returned to its normal size. |
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Contractions & Afterpains
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More common in multiparous women and with breastfeeding
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Changes in the Vagina
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• By 6 weeks postpartum, returns to normal size
• Decreased secretions until ovulation returns • Dryness and dyspareunia (Painful problem until secretions return. |
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Menstrual cycle
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• Non-lactating women
– Resumes by 3 months • Lactating women – Depends on the woman’s pituitary gland system, in conjunction with the frequency & duration of breastfeeding. |
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Lochia
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• Lochia Rubra
– Initially bright red progressing to reddish brown – Consists of blood, decidual and trophoblastic debris – 1-3 days • Lochia Serosa – Pink – Consists of old blood, leukocytes, and tissue debris – Day 3 to day 10 • Lochia Alba – Yellow to white – Until day 21 |
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Nursing Assessment of Uterus
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• Describe location
– Midline – At the umbilicus or where is it r/t finger breadths (cm) below or above the umbilicus • Describe muscle tone – Firm or boggy |
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Uterine Warning Signs
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• Deviated from the midline
• Boggy – Massage until firm – Notify MD/CNM if does not firm with massage or remains above umbilicus after 24 hours |
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Changes in the Perineum
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• Decreased muscle tone
• Episiotomy or lacerations heal in 2-3 weeks • Wounds should be well approximated and free of discharge • Erythema, edema and ecchymosis may be present for 1-2 days • Pain should be mild and easily relieved *****DONT FORGET Kegels***** |
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Endocrine
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Expulsion of the placenta results in dramatic decrease in
hormones • Decrease in HPL (human placental lactogen) causes the diabetogenic effects of pregnancy to be reversed • Estrogen and progesterone levels decrease |
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Endocrine (con’t)
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• Prolactin
– Stimulates breast milk production – Increases in prolactin levels suppress ovulation in breastfeeding women (negative feedback loop) • Oxytocin – Milk ejection (let-down) • Levels of each are influenced by the frequency and duration of breastfeeding |
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Abdomen
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• Takes approximately 6 weeks for the abdominal wall to return
to its almost pre-pregnancy state • Diastasis Recti Abdominis – Abdominal walls separate |
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Changes in the Urinary System
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• Pregnancy adaptations reverse in 6-8 weeks
• Postpartum diuresis occurs – Up to 3000 ml/day in the 1st several days • Risk of urinary retention due to labor trauma and effects of anesthesia – Palpable bladder – Frequent voidings of <150 ml – She should be voiding at least 300-400 ml per void |
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Bladder Warning Sign
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• Inability to void or frequent voids in small amounts (a sense of
urgency) • Palpable bladder • Fundus displaced from the midline • Dysuria not related to the perineum laceration/episiotomy |
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Changes in Bowel Function
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Sluggish bowels for the first few days
– Regardless of type of birth • Constipation is common problem • Flatulence • Fear of having a bowel movement especially if perineum has been repaired. • Afraid of the pain related to incision • Diarrhea if they had Hemabate IM or cytotec PR |
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Cardiovascular
• Warning Signs |
– Increase in diastolic blood pressure with a narrowing pulse
pressure is an early sign of shock. – Hypotension is a late sign of shock – Increase in BP with a headache can be a late onset of PIH – Increasing pulse rate – Drop in hgb/hct – Increasing WBC |
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Changes in the BREAST
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• Expected findings:
– 1-3 days—breast is soft and colostrum is present – 3-4 days—engorgement (swollen, firm and tender) occurs as her milk comes in. – May feel lumpy as lobes produces milk |
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Breast Warning Signs
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• Persistent lump that does not disappear after feeding
• Nipples and areola are red, cracked, sore, blistered, or bruised |
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Postpartum Nursing Care
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• B Breasts
• U Uterus • B Bladder/Bowels • B Bonding • L Lochia • E Episiotomy • H Homan’s Sign • E Emotional Status |
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Breast Assessment
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• Redness, Heat
• Pain • Cracked Nipples • Inverted Nipples • Palpable Mass • Engorgement – If bottle-feeding • Decrease stimulation • Tight fitting bra • Ice packs |
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Bladder/Bowel Assessment
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• 1st void within 4-8 hours after birth
• 1+ proteinuria • Might be a delay in initiating urinary system if patient has had a Foley or trauma • Bowel- sounds, distention, hemrrhoids, constipation prevention |
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Bonding
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• Maintains eye contact with their infant
• Attends to infant’s needs • Demonstrates touching behaviors |
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Assessment of Lochia
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• Lochia
– Amount – Color – Odor – Presence of Clots – Is lochia type consistent with time of birth – Bright red blood—think vaginal or cervical lacerations. |
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Lochia Measurements
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• Scant—less than 1” per hour on pad
• Light—1-4” per hour on pad • Moderate—greater than 4” per hour on pad • Heavy—pad saturated in 1 hour • Hemorrhage—saturated pad in 15 minutes – Requires immediate action – Check BP • Clots—quarter size or less are okay – Large clots greater than a small lemon are not okay |
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Assessment of Episiotomy
(assessment of perineum) |
• Median (midline—MLE)
– Associated with higher incidence of 3rd or 4th degree perineal extensions/lacerations • Mediolateral – Hockey stick looking incision – Multiple problems |
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Perineal Lacerations
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• 1st degree—The skin only
• 2nd degree—Through the skin & muscles • 3rd degree—Through the skin, muscles to the anal sphincter • 4th degree—Through the skin, muscles, anal sphincter into the rectal mucosa into the lumen of the rectum |
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Episiotomy/Lacerations (con’t)
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• REEDA Scale
– Redness – Ecchymosis – Edema – Discharge – Approximation |
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Assess for Hematoma
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(looks like a golf ball)
• Collection of blood that can occur in the vagina, perineum or retroperitoneal area • Perineal pain, inability to void, pressure on the rectum are some signs & symptoms • Signs of concealed blood loss • A surgical incision with removal of the blood clot may be indicated. |
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Homan’s Sign
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– Increased clotting factors place mom’s at high risk for DVT.
If obese the risk goes up. – Check frequently – Assess pedal pulses – Assess size of both legs and temperature of each leg. |
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Emotional Status
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– Signs of depression
– Availability of support—who is at home? – Unusual stressors—single, financial need, teenage mom, etc. |
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Postpartum Nursing Care
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• Pain Management
• Prevention of Infection • Rubella Vaccine, DTap • Rhogam • Breastfeeding support • Education, Education, Education – Self Care – Infant Care – Follow up – Contraception |
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Care of Client s/p C-Section
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• Pain assessment
• Careful monitoring of VS – Respirations/Incentive Spirometer • Fundus and Lochia • Incision • Abdomen • I & O • First 24 hours – Bedrest for first 8-12 hours – Gradual increase of activity – Ambulation with assistance first time out of bed • The next 48 hours—Advance Care As Tolerated – Resuming normal activities – Foley and IV discontinued – Prevent abdominal distention |
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Common Early PP Symptoms
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• Chills
– Expected during the first hour pp, especially after an epidural • After Birth Pains – More common and more severe in multiparas – Breastfeeding stimulates them • Diuresis • Diaphoresis |
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Postpartum Hemorrhage (PPH)
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• Leading cause of maternal mortality in the US
• Postpartum hemorrhage is defined as a loss of blood greater than 500 ml after an uncomplicated vaginal birth • Postpartum hemorrhage can occur – Anytime within 6 weeks after birth |
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Risk Factors for PPH
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• Over distention of the uterus--Causes
• Abnormal Labor • Precip/fast Labor • Uterine atony • Oxytocin induction • C-Section delivery • Use of general anesthesia • Lacerations • Bladder distention • DIC—disseminated intravascular coagulation • Retained placental fragments |
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Causes of PPH
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• Early PPH
– Uterine atony & lacerations • Late PPH – Retained placenta fragments or organized blood clot |
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Uterine Atony
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• Is the inability of the muscles of the uterus to contract and
stay contracted around the open blood vessels from the placenta site • Factors that contribute are – Full bladder – Uterine trauma – Use of drugs like Magnesium Sulfate – Retained placenta fragm– Hypocalcemia |
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Vaginal, cervical & perineal lacerations
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– Bright red bleeding from the genital tract
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Placenta accreta
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retained placenta
– Careful examination of the placenta after birth to ensure all segments have been expelled. |
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Nursing Actions for PPH
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• STAY WITH PATIENT, SUMMON HELP FROM ROOM
– Massage fundus immediately – Insert large bore IV catheter – Increase IV rate – Administer Oxygen – Notify Provider--SBAR |
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Nursing Interventions for PPH
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• Assess bladder for distention
• Insert Foley—I & O’s • Obtain blood for type & cross, CBC & clotting times • Apply pulse ox • Monitor VS • Elevate legs to 20-30 degrees above the head to increase venous return • Explain procedures • Provide emotional support |
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emorrhagic (hypovolemic shock)
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• Signs
– Rapid and shallow respirations – Rapid, weak irregular pulse – Decrease BP (late sign) – Skin is cool, pale & clammy – Decreased urine output – LOC—lethargy to coma – Mental status—anxiety to coma |
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Medical Management of hypovolemic shock
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• Summon assistance and emergency equipment
• Identify where the blood is coming from • Stop the blood loss • Start an IV to maintain circulating volume |
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Medical Management of hypovolemic shock (con't)
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• Provide Oxygen to increase Saturation of RBC
• Insert a Foley to assess kidney function & I &O • Ensure patent airway • Continue to monitor well-being – VS, LOC & bleeding. |
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Medications Used to Manage PPH
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Oxytocin
– IV or IM • Methergine (methylergonovine) – IM or IV or PO – Use with caution with HTN disorders • Prostaglandin F (Hemabate) – IM or Intramyometrium – Contraindicated in asthmatics • Cytotec – Per Rectum |
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Endometritis
• Signs & Symptoms |
– Uterine tenderness & enlargement
– Foul odor or purulent lochia – Malaise – Fatigue – Tachycardia – Temperature elevation |
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Nursing care for Endometritis
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• Antibiotics
• Antipyretics • Analgesics • Fowlers position to promote drainage of lochia |
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Mastitis
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• Almost always unilateral
• Infected nipple fissure usually is the initial lesion • Inflammatory edema and engorgement of the breast soon obstruct the flow of milk—blocked milk duct which than progresses to generalized infection of the breast |
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Mastitis
• Signs & Symptoms |
– Painful & tender localized hard mass which has reddened area of one breast
– Enlarged lymph nodes in the axilla – Fever, chills and malaise |
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Mastitis nursing care
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– Antibiotics
– Continue to breast feed infant – Empty each breast after feeding – Apply ice packs, raw cabbage to affected breast – Wear proper fitting bra |
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Self care for mastitis
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• Wash hands before feeding
• Expose nipples to air • Check infant latch • Encourage infant to empty breast • Increase feedings • Report redness or fever • Apply ice packs • Massage distended area as the infant nurses • Soak breasts in warm water or in the shower |
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Rubin’s Phases of Maternal Adjustment
• Taking In |
– Period of dependent behavior
– Focus on self – Verbalizes need for sleep and food – Passive attitude |
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Rubin’s Phases (con’t)
• Taking Hold |
– Transition from dependence to independence
– Widens focus – Becomes independent in self care – Open to teaching on care of self and infant – May lack confidence in caretaking skills |
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Rubin’s Phases (con’t)
• Letting Go |
– Taking on new role and responsibilities (especially 1st time
moms) – Increasing independence – Recognizes infant as separate from self – Adjustment of family relationships to accommodate infant are complete – Reassertion of relationship with partner |
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Postpartum Blues
“Baby Blues” |
Affect most women (70%)
• Begins 1st week and last no longer than 2nd week • Usually mild & transitory • Severe or persistent symptoms need referral for evaluation for postpartum depression |
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Symptoms of postpartum blues
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• Emotionally labile—”cries easily”
• Depression • Restlessness • Fatigue—Extreme tiredness • Insomnia—combined with fatigue—vicious cycle • Headache • Anxiety • Sadness • Anger |
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Thromboembolic Disease
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• Superficial Venous Thrombosis
• Deep Vein Thrombosis • Pulmonary Embolism |
