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Maternity - Post
Postpartum - Normal and Abnormal
| Question | Answer |
|---|---|
| Immediately after birth, the uterine wall is? | Jagged and torn |
| Should the uterine wall scar? | No - if it scars a future pregnancy cannot attach there |
| How long does postpartum or peurperium last | Six weeks |
| What is the endometrial tissue that has built up over the 9 mos. of pregnancy called? | Lochia |
| What needs to happen to the lochia now that pregnancy is over? | It needs to be shed |
| What are afterpains? | Contractions of the myometrium |
| What is lochia? | Vaginal discharge composed of endometrial tissue, blood and lymph |
| Does the amount and color of lochia change? | Yes, |
| On days 1-3 following birth, what color should the lochia be and what is it called? | lochia rubra - bright red |
| On days 3-10 following birth what color should the lochia be and what is it called? | lochia serosa - pink to brownish pink |
| On days 10-21 following birth what color should the lochia be and what is it called | lochia alba - white |
| With a c-section, what amount of lochia should the pt. see/ | Should see less because the uterus was "cleaned" out during c-section |
| What is the relationship between breastfeedng mothers and lochia? | breastfeeding mothers tend to have less lochia due to increased uterine contractions or afterpains caused by nursing |
| Will ambulating mothers see more or less lochia? | More for a short period of time |
| Why is absence of lochia not a good thing? | It may indicate the presence of an infection or even an occlusion |
| Should the flow of lochia be constant or stop-and-start? | Stop-and-start. A constant flow may indicate bleeding from something other than the uterine wall. |
| Describe the cervix after birth. | It will be partially open, it will close during the peurpurium, but will be a slit-like opening - not pefectly round; there mayy be lacerations as well |
| What is involution? | The returning of the uterus to its normal size and position. |
| What size was the uterus before pregnance | Approx. the size of a pear |
| To what size does it return after birth | To the size of a pear. |
| How long does it take the uterus to return to its pre-pregnancy size? | 6 weeks |
| What assessment is used to determine size of uterus after birth? | fundal height |
| By how much should the uterus reduce in size per day? | It should descend approximately 1 finger breadth per day |
| Where should the fundus be after birth | It should be slightly below the umbilicus and not displaced to one side or other. |
| If the uterus is displaced to one side or the other, what is likely to be the cause | the bladder may need to be emptied |
| By what day should the nurse no longer be able to palpate and assess the fundus/uterus | by the 10th day postpartum |
| If the uterus does not return to its pre-pregnancy size by 6 weeks, what is it called | subinvolution |
| With a vaginal deliver, what will typically be seen? | C/O tenderness from stretching, erythema, edema, ecchymosis, absence of vaginal rugae |
| When should perineal muscle tone return? | 2-3 weeks |
| When should vaginal rugae return | 3-4 weeks |
| When should lacerations / episiotomies be healed by? | 5-6 weeks |
| What should happen to any sutures used in the perianeal area? | They should be absorbed |
| Hemorrhoids should diminish by when | the end of the 6 wk postpartum period |
| What should you expect to see w/ the urninary tract immediately postpartum | Should expect to see diuresis |
| Why would there be diuresis? | Need to get rid of excess fluids: the 50% increase in blood volume during preg., and the IV fluids used during L&D |
| What happens when the bladder is full and why is this bad? | The bladders displaces the uterus and can decrease contractions and increase postpartum bleeding |
| What can restrict urine flow after birth | There may be swelling in the peri area that can restrict urine flow |
| Why is it important to make sure mom is urinating? | so the full bladder doesn't diplace the uterus, interfere w/ contractions, or so that she doesn't have residual urine which can lead to a UTI |
| When we palapate the fundus, what else should we palpate? | THe bladder - should not find the bladder unless there is too much urine in it |
| When will kidney function return to normal? | by 1 month |
| Until bladder tone returns to normal, what is the new mom at risk for? | Residual urine and UTIs |
| What do the breasts produce early postpartum | Colostrum |
| How long does colostrum last? | 2-3 days |
| What is in colostrum? | lots of protein, vitamins, and minerals, but not a lot of calories |
| What effect does colostrum have on the newborn? | a laxative effect,helps to pass the 1st stool of meconium |
| What is it called when a mom's milk comes in? | Engorgement |
| When does engorgement happen? | 3 day postpartum |
| Production of milk is called | Lactation |
| What hormone causes the production of milk? | prolactin - from the anterior pituitary |
| What hormone causes the let of milk | oxytocin |
| What else does oxytocin cause? | Contractions - AKA afterpains, and they increase w/ breastfeeding which helps to reduce the bleeding |
| Which moms have the most painful contractions? | Breastfeeding moms, multigravida moms, and overextended uteruses (uteri?)? |
| How do some women describe afterpains? | As sever menstrual cramps |
| If the mom chooses not to breast feed how long before the breasts return to normal | 1-2 weeks |
| How much blood is lost during the average vaginal delivery: | 500 ml |
| How much blood is lost during the average c-section | 1000 ml |
| How much fluid do we expect the mother to lose during the first 5 days (including blood)? | about 2 L : blood, diuresis, diaphoresis, etc. |
| Why would the lab values for H&H (hematocrit/hemoglobin) not have great meaning postpartum? | Due to a lot of fluid volume fluctuation, the lab values may be falsely elevated or diminished, but will be more normal by 8 wks postpartum |
| Immediate postpartum, what symptoms might we siee? | diaphoresis,chills and shock-like symptoms, orthostatic hypotension |
| What happens to the WBC postpartum? | WBC will elevate, it's a normal response to the inflammation of L&D, will return to normal in 2 wks, not a good indicator of infection at this time |
| What happens to the joints during pregnancy | Progesterone makes the joints more flexible |
| What happens to the mom's center of gravity | It is off during pregnancy, but the center of gravity and joint stability should return to normal within 6 wks postpartum |
| What is diastisis recti | The separation of the abdominal muscles - vertically |
| How should we assess diastisis recti | HAve the mot mother lie down on talbe then sit up, will notice a vertical bulge between the muscles if there is diastisis recti |
| How long before diastisis recti improves/ | Should iprove by 6-8 wks, but the muscles do not grow back together - have to work on other muscles to pull it together |
| Weakened abdominal muscles postpartum may also contribute to what postpartum/ | Constipation |
| What are striae and do they disapear? | Stretchmarks, and no,they do not, but they may change color |
| Will pigmentation levels return to normal? | AS hormone levels drop pigmentation levels should return to normal |
| How soon do hormone levels begin to change? | AS soon as the placenta is expelled |
| The placenta is the source of what hormones? | estrogen/ progesterone |
| What hormone begins to increase as soon as the placenta is expelledcd? | Follicle stimulatin hormone (FSH) |
| How soon does the menstrual cycle return | 6-12 wks, may take longer if breastfeeding |
| How soon does ovulation return | 12-18 wks, may take longer if breastfeeding |
| Can ovulation return with the menstrual cycle? | Yes, and it's a lovely surprise |
| Immediately following L&D, where should the fundus be | at or below the umbilicus, midline and should be firm. |
| If the fundus is not firm, what intervention should the nurse utilize? | Fundal massage for a soft/boggy fundus. splint/immobilize the fundus over the pubis symphisis and massage w a circular motion |
| If the fundus is firum, do we massage | NO, will overstimulate muscles of uterus, cause it to fatigue faster. Just assess and check it again late |
| What should be teach regarding fundal massage? | Why we do it, the mother to assess her own, and how important it is to do even if it's painful |
| What is lochia | Vaginal discharge following L&D |
| What should we monitor lochia for | amount and type |
| How do we monitor the amount of lochia | pad count |
| How do we document the amount of lochia on a pad | Over an hour: Scant - 2", 10ml Light -4", 10-25 ml Moderate - 6", 25-50" Large/Heavy - 8", 50-85 ml, or pad saturated in 2 hrs time Excessive - pad satur'd in 15 minutes |
| Where else should we check for blood/lochia | Underneath the pt.'s hips |
| Some facilities, particularly crit care will calcualte the wt of the lochia, what is the conversion factor/ | 1 ml = 1 gram |
| What increases lochia? | movement, ambulation, activity, breastfeeding |
| Why shouldn't we use heat on abdoment after delivery/ | It increases vasodilation, bleeding will increase |
| What is the easiest way to track urine output | I's/O's |
| No urine means what | urine retention in bladder, risk of UTI, uterus not contractin, increase in bleedding |
| Small amts of urine mean | urinary retention, need to palpate for full bladder, do everything to get her to void, may be feeling effects of epidural, anesthesia, |
| What is a cath for residual urine | pt. voids, then we cath the measure urine remaining in bladder |
| What do we teach w/ peri care | Wash hands, use peri bottle w/ warm water, no tissue paper/wiping, secure peri pad - no sliding back/forth - cross contamination, remove and apply pad front to back, don't handle pad, no tampons, no douche ever, no sex until 6 wk checkup |
| What nonpharmacologic intervention can we use on the peri area | Ice-1st 24 hrs for short periods; after 24 hrs, heating pads, heat lamps, sitz baths,tucks pads --there may also be topicals ordered |
| How do we assesss the peri area | have pt. side lie (R or L), easy visualization, can also see bed pad, assess for REEDA (redness, edema, ecchymosis, Discharge, approximation) |
| What do we worry about w/ the breasts | redness, cracking, dryness, engorgement |
| How to cleanse breasts | ew/ clean warm waterr, no soap |
| What do we teach? | to support bra, not too tight, breast pads, |
| Teach non-breastfeeding mom | to avoid all forms nipple stimulation, dn't face shower, etc. |
| Teach for constipation | fluid, fiber, activity, stool softener |
| Teach for muscle tone | abdominal tightening, head lifts, pelvic lift, kegels |
| What restrictions on mom's activity? | 1st 2 wks - nothing heavier than the newborn, no drive, no lifting, nap when baby naps, showers/sponge baths no tubs |
| Teach about nutrition | Protein, Vitamin C, iron supplement, multivitamin, variety macronutrients |
| How many extra calories if breastfeeding | 500 extra calories than before preg, (only did 300 per baby during), plenty of fluid 8-10 glasses |
| What is mom's primary focus after delivery | fluid, nutrition and sleep, care for self so can care for infant and bond |
| What must be given within 7 hrs of delivery | Rhogam/Rogam for Rh-mom w/ Rh+ baby |
| What is uterine atony | uterine w/ no muscle tone, no strong contractions |
| What % of early postpartum (1st 24 hrs) hemorrhage is due to uterine atony | 90% |
| What do we worry abot w/ uterine atony | Blood loss leading to hypovolemic shock |
| What are the S/S of hypovolemic shock | BP down, Hr up, |
| What meds can be administered to produce contractions | oxytocic meds |
| What causes early postpartum hemorrhage | Uterine atony |
| What causes late (24 hrs after birth to 6 wks) hemorrhage? | retained placental fragments |
| What are the treatments for retained placental fragments | oxtocin / methergen to pass fragments, or may need DNC / DNE |
| What should you do if you think a pt. hs a complication related to blood loss | Keep them NPO |
| What are the symptoms of hematoma? | Uterus/fundus/lochia will be normal, blood will collecgt in tissue, may be a pocket or bulging area that is blue or purple, C/O severe pressure, unrelenting/unrelieved pain, can be visible or hidden, |
| Lacerations | Can occur anywhere in reproductive tract |
| Symptoms if lacerations are source of blood loss | Uterus/fundus will be normal, lochia will be a continuous flow or trickle |
| What is a peurperal infection? | An infections directly related to childbirth: from episiotomy, lacerations, surgical incisions, U TI |
| What are S/S of peurperal infections? | Expect elevation in temp immediate postpartum, suspect infection - temp will be >100.4 or will persist for more than 24 hrs. WBC and Temp not reliable after delivery, WBC count does up anyway. Temp must last at least 2 days before we intervene |
| What is the concern w/ peurperal infections | Can lead to septic shock and death |
| What preventative teaching do we do related to peurperal infection | pericare, handwashing, hnutrition, rest. Teach pt. S/S of infection before sending home, absence of lochia may be bad, watch urine output, chk for urine color, odor, cloudiness |
| What is endometritis | Infection of endometrium, increased risk w/ retained placental fragments |
| What will pt. complain of w/ endometritis? | uterrine tenderness, utersu larger than expected, severe cramping, lochia may be foul or absent (cervis blocked),excessive lochia, lochia rubra persists after first few days |
| What do we treat endometritis with? | antibiotics |
| What is mastitis | Infection of the breast, can affect one or both |
| When do we commonly see mastitis | 2-3 wks after birth |
| S/S of mastitis include | S/S of infection/ inflammation |
| The infection in mastitis is normally where | in breast tissue not the lactiferous ducts |
| What are the goals w/ mastitis | Relieve pain, treat infection, maintain lactation |
| When is it safe to breastfeed w/ mastitis | when infection is just in tissue |
| WHen is it NOT safe to breastfeed w/ mastitis | When infection becomes an abcess and infection may ahve reached lactiferous ducts - will have mother pump, then throw away milk |
| What is the treatment for mastitis | safe antibiotics and safe analgesics, ice or heat for pain, severe abcess may need I & D |
| Until estrogen and progesterone levels are reduced, what is still circulating in the blood | Extra clotting factors |
| What is thrombophlebitis | inflammation of the vein |
| Thrombophlebitis can be... | superficial - actually see the vessel, raised, hard red (treat w/ heat, elevation analagesics; or DVT will see erythema, edema, and pain - (treat ,heat, elevation, analgesics, and anticoagulants -w/ risk) |
| How can thrombophlebitis be prevented | early ambulation, range of motion, SCDs and TEDs |
| What is a pulmonary embolism | a moving particle, can be a clot, vernix, hair from fetus, air bubble |
| A pulmonary embolism occurs... | Very suddenly, little can be done, often have very few symptoms |
| A large pulmonary embolism is usually... | fatal |
| How is a pulmonary embolism treated? | Symptomatically - O2, analgesics, rest, anticoagulants (although risky), but no thrombolytics |
| What is subinvolution | slower than normal return of the uterus to prepregancy size |
| Causes of subinvolution may be: | infection, retained placental fragments, sometimes IDK |
| How do we assess for subinvolution | Things not what we expect, may still be able to find fundus, have persistnet lochia or slow progression from one stage to next, C/O discomfort - espec. w/ palpation |
| How do we treat subinvolution | Prefer to treat cause: infection w/ antibiotics, retained placental fragments w/ DNC/DNE, maybe another dose of oxytocic to stimulate uterine contraction |
| How are postpartum blues different from postpartunm depression? | Postpartum blues can last whole 6 wks of postpartum, due to hormone fluctuations, physical changes, sleep deprivations, not feeling as happy as she thinks she should, etc. |
| Postpartum depression is... | Depression that begins within the 1st month after pregnancy, mom has inability to interact/bond w/ infant, lack of interest in self or baby, difficulty sleeping not due to infant, difficulty concentrating, persistent negativity - mom can't move forward |
| Postpartum psychosis however differs because | Mom is not connewcted to reality, not making good choices, not taking care of self baby, doesn't understand right/wrong, has hallucinations, delusions, usually see in 1st 6 wks. progression to not understanding reality - HAS UNDERLYING PSY DISORDER |
| Birth control | Ask about birth control as discahrge from the hospital. Teach no sex until post partum visit 4-6 wsks after birth. |
| What is the only 100% effective birth control method | ABstinence |
| What kind of birth control pill is recommended for breastfeeding mom | Progesterone/progestin "Mini" pills, not pills w/ estrogen |
| How do the pills work? | some thicken cervical mucus - inhospitalbe for pregnancy; some stop ovulation altogether |
| Birth control pills add what risk factor? | put woman at a highher risk for clots, may cause/contribute to cardiac problems, irregular heart beats,some have high risk of reproductive cancers - cervical, breast, endometrial |
| Birth control pills are not recommended with... | Smokers, women over 35 or those w/ decreased liver function |
Created by:
amyswabe@comcast.net