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71 Cards in this Set
- Front
- Back
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Puerperium |
Period of time following delivery until uterus returns to a pre-pregnancy state (usually 3-6 weeks)
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Involution
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The return of the uterus to a pre-pregnant state
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What is the uterus like through the process of involution?
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* End of third stage of labor- midline, 2cm below
* 12 hr PP- 1 cm above * Fundus descends about 1-2cm/day |
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What should be covered in a history?
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type of delivery, complications, significan history, blood type, rubella status, perineal condition, other incisions, breast/bottle feeding, PP hct value, misc. info (foley/IV/voiding status)
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What should be included in a general assessment of PP woman?
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LOC/Affect
Anxiety/pain/fatigue Coping skills/mechanisms Relationships: SO and family Bonding |
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What to ask a PP woman?
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Pain rating?
Breastfeeding? Breasts/nipples? Cramping (afterbirth pain, increased with breastfeeding and multip)? Stitches? Passed gas/BM? |
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How often do you take VS on a PP woman?
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1st hr= every 15 minutes
2nd hr= every 30 minutes (unless birth complications) Then 4-8 hrs per unit guidelines |
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Postpartum Perineal care
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Flush with warm water, front to back
For first 24hr, ice pack on perineum Anesthetic foams and prays Inflatable ring (not recommended, can cause perineum to swell more) Sitz bath for hyperemia (rarely done now) |
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Cardiac assessment of PP woman
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Heart sounds
Peripheral pulses Skin temp Edema Homan's sign (rare now) DVTs (if walking w/o pain, probably none) Blood loss |
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Blood loss
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Vaginal delivery= 200-400cc (up to 500)
C-section= 500-1000cc Assess for fatigue, lethargy, fainting, thirst, pallor, compare pre and post Hct/Hgb Encourage hydration and nutrition NOTE: providers underestimate blood loss, peripads hold about a unit of blood, and compare labs and think critically |
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Respiratory assessment of PP woman
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Breath sounds
Respiratory effort |
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GI assessment of PP woman
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Fluid status/ dietary intake
Bowel sounds Abdominal distention |
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Urinary assessment of PP woman
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Count 3 voids, must be fully emptying bladder
Bladder distention |
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Breast assessment of breast feeding PP woman
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Soft/filling/lactating/engorged
Nipples- intact/cracked/blistered Colostrum production Milk production w/in 48-72 hrs Breast consistency changes from soft to firm Engorgement |
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Breast assessment of bottle feeding PP woman
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Soft/filling/lactating/engorged
Nipples- intact/cracked/blistered Bind breast (with very tight bra or ace bandage) Do not stimulate (no warm water, etc) Don't express milk, they will produce twice as much Ice packs NOTE: if a woman decides to bottle feed the nurse needs to teach the mom how to dry up her breasts |
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Specific, focused, PP assessment of the fundus
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Height in r/t umbilicus (measured in cm/finger breadth above/below/at)
Tone (firm/boggy/firm with massage) Deviation (usually indicates full bladder) NOTE: when assessing fundal height you need to support the lower uterine segment |
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What is the significance of a boggy fundus?
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Abnormal, should be reported
Associated with PP hemorrhage (uterus is not clamped tightly enough on blood vessels to stop bleeding) |
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Specific PP assessment of the bladder
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Distention
Suprapubic tenderness Presence of foley |
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Perineum
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MLE (midline episiotomy)/laceration
Hematoma Hemorrhoids |
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Specific PP assessment of lochia
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Lochia is vaginal discharge after delivery
Day 1-3= rubra (red) Day 3-10= serosa (pink-brown) Day 10-21= alba (white, yellow) |
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PP specific assessment for c-section
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Epidural/general anesthesia
Breath sounds Bowel sounds Abdominal dressing/incision Pain control- epidural/PCA/PO IV |
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What does "BUBBLE" stand for when assessing the PP woman?
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Breasts
Uterus Bowel Bladder Lochia Episiotomy/extremities |
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Episiotomy and lacerations- what is the difference between supported and unassisted delivery? What kinds of lacerations happen?
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Lacerations happen with crowning of the fetal head but differ when the head is supported between contractions and when it is not
1. Crowning with lubrication, stretching, and supported delivery leads to possible first or second degree lacerations 2. Crowning of fetal head in unassisted spontaneous birth commonly leads to lacerations from 1st to 4th 3. Crowning of fetal head with midline or mediolateral episiotomy can extend to a 3rd or 4th degree laceration |
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Degrees of laceration
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1st= limited to skin and superficial structures
2nd= reaches into the perineal muscle 3rd= extends into the anal sphincter 4th= involves the anterior rectal wall |
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Puerperal infection
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Normal vaginal bacteria is introduced during vaginal exams and use of instruments. The bacteria can enter lower uterine segment and placental site leading to circulatory bacterial transport OR enter the body through episiotomy and lacerations which is warm and moist leading to endometritis, myometritis, parametritis, parametrial abscess, rupture, lymphatic transport and periotonitis.
NOTE: strep A sepsis is deadly NOTE: patient will complain of abdominal pain |
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Hematoma in PP
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Vessel trauma, bleeding into tissues, and hematoma formation can lead to vulva and vaginal hematomoma, rupture but the clots are expected to resolve and reabsorb OR if the hematoma is in the vagina or retroperitoneal area will cause severe pain. pressure, lateral/uterine pain, flank pain leading to rupture/extension, hemmorhage, surgical evacuation, ligation and vaginal packing
NOTE: if pain is getting worse, this is not normal and you need to wonder WHY |
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Venous thrombosis in PP woman
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Risk factors include vessel trauma, puerperal infection (these can lead to thrombophlebitis and risk of PE, thrombosis of pelvic veins) and venous stasis
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Signs and symptoms of PP hemorrhage
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Large amount of lochia, pallor, increased HR, lowered BP, altered LOC, shortness of breath, pulses weak and thready, UOP drops, atony
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Atony
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boggy fundus
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What is the most common cause of PP hemorrhage?
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Bladder distention
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What do you do for PP hemorrhage?
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Empty bladder
Meds (oxytocin causes uterus to cramp down on placental site) Bimanual compression, fundal massage Fluid replacement Transfuse blood products Notify MD Oxygen Position: side lying and elevate extremities Labs |
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PP hemorrhage due to retained placental fragment: characteristics and treatment
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Subinvolution (failure of the uterus to return to its normal size following childbirth)
Ineffective contractions Treatment:uterine exploration with removal of fragment |
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What are the psychosocial states PP?
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1. Taking-in, day 1-2
2. Taking-hold, 10 days to several weeks 3. Letting-go, first 2-6 weeks PP |
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Taking-in
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Day 1-2 PP
Mother is very focused on herself and relies on others during this time, wants rest and nutrition |
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Taking-hold
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10 days- several weeks
Time when the mother is very focused on the care of the baby and feeling like she's a competent mother. She needs and wants help, thinks about body image |
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Letting-go
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First 2-6 weeks PP
Thinks about the management with the family, needs reassurance with her partner, may be when sexual intimacy begins again |
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What is included in psychosocial adjustment?
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Attachment and bonding
Parental, sibling, grandparent adaptation Cultural diversity |
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What are the PP blues?
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Discomfort, fatigue, and emotional let-down along the lines of mild depression due to hormonal changes/fatigue and pain/change in relationships/role strain
Early onset, self-limited (3 days), mild dpression, anxiety, irritable, fatigue, sudden crying Treat with support, information, reassurance VERY common in women |
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What is PP depression? Who is at risk?
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Late onset, persistent > 2 wk, hopelessness, helplessness, sleep/appetite changes, feeling of fatigue/ worthlessness
Mother may have history of major depression, previous PPD, low self-esteem, unwanted pregnancy Treat with psychiatric care due to suicide risk and risk to infant |
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What is PP psychosis? Who is at risk?
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Hx of bipolar, schizophrenia, previouw puerperal psychosis, socioeconomic stressors
Will see agitation, irrationality, labile mood, confusion, delusion, hallucinations NOTE: be very concerned with suicide and infanticide risk Treat with inpatient psychiatric care |
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What is included in PP discharge teaching?
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1. Sexual activity including fears and contraceptive use
2. Follow-up postpartum visit 3. Exercise- no lifting over 10-15lbs until bleeding slows down |
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What shots does a mother need before discharge? |
1. To prevent Rh isoimmunization when mother is Rh- and baby is Rh+ give Rhogam w/in 72 hrs of delivery
2. Rubella if nonimmune |
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If you have a PP woman with boggy fundus and heavy lochia flow, what are the priority interventions?
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1. Massage fundus till firm- express clots
2. Check for bladder distention 3. Standing order for oxytocic meds (pitocin/methergine) 4. Change pad and monitor flow frequently 5. Increase frequency of assessment 6. Breastfeeding 7. Notify provider |
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You have a patient with perineal pain and hemorrhoids. What relief measures and assessment would you do?
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1. Assess pain before and after intervention
2. Ice packs for 12-24 hrs 3. Heat measures (sitz bath) after 24 hrs 4. Perineal cleansing 5. Positioning to decrease pressure on the area 6. Topical meds (Tucks, Epifoam, Dermoplast spray) 7. PO meds if no relief |
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What is your intervention if fundus is not midline?
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Have patient void, reassess
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What are the teaching needs of a PP woman?
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Prevention of infection
Peri-care Breast care Ambulation Diet Elimination |
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A woman who just gave birth to twins plans to breastfeed. She breastfed her first child successfully but complains of cramping. What factors are involved in her cramping?
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Pariety
Twin gestation contributes to loss of muscle tone BF physiology Interventions: 1. The nurse should teach the client that suckling stimulates releases of oxytocin --> uterine contractions. This is a normal process that aids in the prevention of PP hemorrhage, will subside in 47-72hrs 2. Offer NSAID analgesia 30 min prior to nursing 3. Place client in prone position with small pillow or rolled blanket under her abdomen 4. Empty bladder frequently |
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A patient c/o constipation during the last few months of her pregnancy. What can you do to prevent/alleviate constipation PP?
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1. Early and frequent ambulation
2. Increase PO fluids, dietary fiber 3. Avoid narcotics, administer stool softener 4. Perineal comfort measures |
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A PP woman has a pulse rate of 52. Does this indicate a problem with her involutional process?
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No. Pulse rate of 50-60bpm is normal PP. The return of increased amount of blood flow to the central circulation following delivery and increased COP allows for a slower heart rate
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What is the normal pulse rate for a PP woman?
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50-60 bpm
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A woman who gave birth to twins 2 days ago has a firm fundus at 1 below/umbilicus. The fundus is expected to descend 1 cm per day, why hasn't this patients? |
Over-distention secondary to twin gestation contributes to a slower descent
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What do you look for when assessing an episiotomy?
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Approximation
Absence of edema Absence of discharge Sight erythema indicates normal inflammatory response |
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On the third day postpartum, what changes should be expected in the lochial flow?
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Change from lochia ruba to lochia serosa and a decrease in flow
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How do you assist a woman to breastfeed?
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1. Ensure the infant is calm by holding/stroking/talking to him softly
2. Observe breastfeeding technique 3. LATCH score: latch, assistance, type of nipple, comfort, hold NOTE: reassure the mom that breastfeeding does not come easily, it requires knowledge, patience, skill and motivation. |
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Preventing engorgement
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Early and frequent BF will prevent/reduce the severity
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Preventing cracked nipples
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Use various positions for feeding, correct latch technique, apply colostrum and allow to air dry, no soap to nipples/breasts, olive oil/lansinoh
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How to know a baby is getting enough breast milk?
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1. Listen to the baby, a soft "ka" indicates he is swallowing, look for content behavior/posture after BF
2. Until milk comes in, 4-6 wet diapers/24 hr= adequate hydration 3. After milk is in, 8-10 wet diapers and 2 or more stools in 24 hr period 4. Consistent weight gain |
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Teaching after a rubella vaccine
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1. Site will be tender
2. May have low-grade fever 3. Birth control is essential for at least one month due to teratogenic effect |
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What are the teaching needs of a PP woman?
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Prevention of infection
Peri-care Breast care Ambulation Diet Elimination |
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A woman who just gave birth to twins plans to breastfeed. She breastfed her first child successfully but complains of cramping. What factors are involved in her cramping?
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Pariety
Twin gestation contributes to loss of muscle tone BF physiology Interventions: 1. The nurse should teach the client that suckling stimulates releases of oxytocin --> uterine contractions. This is a normal process that aids in the prevention of PP hemorrhage, will subside in 47-72hrs 2. Offer NSAID analgesia 30 min prior to nursing 3. Place client in prone position with small pillow or rolled blanket under her abdomen 4. Empty bladder frequently |
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A patient c/o constipation during the last few months of her pregnancy. What can you do to prevent/alleviate constipation PP?
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1. Early and frequent ambulation
2. Increase PO fluids, dietary fiber 3. Avoid narcotics, administer stool softener 4. Perineal comfort measures |
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A PP woman has a pulse rate of 52. Does this indicate a problem with her involutional process?
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No. Pulse rate of 50-60bpm is normal PP. The return of increased amount of blood flow to the central circulation following delivery and increased COP allows for a slower heart rate
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What is the normal pulse rate for a PP woman?
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50-60 bpm
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A woman who gave birth to twins 2 days ago has a firm fundus at 1 below/umbilicus. The fundus is expected to descend 1 cm per day, why hasn't this patients?
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Over-distention secondary to twin gestation contributes to a slower descent
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What do you look for when assessing an episiotomy?
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Approximation
Absence of edema Absence of discharge Sight erythema indicates normal inflammatory response |
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On the third day postpartum, what changes should be expected in the lochial flow?
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Change from lochia ruba to lochia serosa and a decrease in flow
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How do you assist a woman to breastfeed?
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1. Ensure the infant is calm by holding/stroking/talking to him softly
2. Observe breastfeeding technique 3. LATCH score: latch, assistance, type of nipple, comfort, hold NOTE: reassure the mom that breastfeeding does not come easily, it requires knowledge, patience, skill and motivation. |
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Preventing engorgement
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Early and frequent BF will prevent/reduce the severity
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Preventing cracked nipples
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Use various positions for feeding, correct latch technique, apply colostrum and allow to air dry, no soap to nipples/breasts, olive oil/lansinoh
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How to know a baby is getting enough breast milk?
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1. Listen to the baby, a soft "ka" indicates he is swallowing, look for content behavior/posture after BF
2. Until milk comes in, 4-6 wet diapers/24 hr= adequate hydration 3. After milk is in, 8-10 wet diapers and 2 or more stools in 24 hr period 4. Consistent weight gain |
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Teaching after a rubella vaccine |
1. Site will be tender |
