Postpartum
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| Hormonal changes occur secondary to what in the PP period | Delivery of the placenta (and hormones)
Change in prolactin secretion
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| Prolactin | ant. pituitary, suppressed by estrogen in pregnancy
Increases immediately after delivery - peaks at 3 hours PP
Stimulated by suckling - stimulates alveolar cells to produce milk.
In non-lactating women - falls to non-pregnant levels at 7-14 days
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| Oxytocin | Produced in hypothalamus, stored and secreted by posterior pituitary
Causes myoepithelial cell contraction leading to milk ejection
Responsible for contraction and involution of the uterus
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| Oxytocin release is inhibited by: | Fear, anxiety, embarrassment
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| Oxytocin release is enhanced by: | Relaxation, orgasm, baby cry, breast stimulation
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| Estrogen | Decreases rapidly PP with removal of placenta
estradiol reaches <2% preg val by 24 h aiding in initiation of lactation
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| Progesterone | 24-48 h: level similar to luteal phase
3-7 d: level = fallicular phase
decrease aids in lactation
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| HPO axis | Suppressed in pregnancy
Estrogen and progesterone slowly increase and pituitary function resume at 4-6 weeks pp.
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| Hemoglobin and HCT are affected PP by: | Hydration, fluids retained in labor and reduction in blood volume
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| 9 predisposing factors for thromboembolic disease in the PP woman | Venous stasis from dilation of vein and compression of uterus
Prolonged bed rest
Lack of activity or ambulation
Hypercoagulation disorders
Instrument assisted and cesarean birth
Hemorrhage
Sepsis
Multiparity
Advanced maternal age
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| Blood loss: - 1 pt drop in HCT = - 1 pt drop in HGB = | HCT - 250 ml
HGB - 500 ml
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| Renal pelves and ureters return to normal by: | 4th PP week
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| Bladder is edematous and hypotonic immediately PP resulting in: | Over distention and incomplete emptying - encourage periodic voicing
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| What % of women have non-pathologic proteinuria up to 2nd day PP? | 40%
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| Diuresis begins______ _______ _______ and lasts up to the ___ PP day? | Shortly after delivery
5th
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| Urine output may equal _______mL/D PP | 3000 mL
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| Urinary incontinence may persist up to _____ postpartum | 6 months
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| What are the 3 processes to uterine regeneration? What speeds up the process? | Contractions, autolysis, and placental site regeneration
Breastfeeding
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| Immediately following delivery uterus is at?________ at 1-2 hours uterus is at?________ Uterus descends __ finger breadth/d? At 2 weeks uterus is approximately __ week size. Uterus is at the non-pregnant size at ____ to ____ weeks PP? | 2/3 btw pubis and umbilicus
umbilicus or 1 fb below
1
12 week
4-6 weeks
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| Endometrium takes ___ weeks to regenerate? Placental site takes ___ weeks to regenerate? | 3 weeks
6 weeks
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| Lochia arises from the? | Superficial layer of the uterine decidua
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| Lochia rubra lasts___ days Color? Contains mostly? | 4 days
Bright red
Blood
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| Lochia Serosa lasts __ days Color? Composed of? | 22 days
pink
serous fluid, decidual tissue, leukocytes and erythrocytes
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| Lochia Alba lasts ___ days Color Contains: | 7 days
Whitish
erythrocytes and decidua
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| Mean duration of lochia is __ days but can last up to __ days | 33 days
60 days
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| Engorgement may occur btw the __ and ___ PP day and resolves in _______ hours | 2nd and 4th
24-48
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| Resumption of ovulation is associated with a rise in? | Plasma progesterone
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| Initial menses following delivery is anovulatory in | 75% of women
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| Breastfeeding - prolactin Secreted by: Influence in PP State | Anterior pituitary
Stimulated alveolar cells to produce milk; initiates lactation with suckling; inverse relationship btw catecholamines and PRL
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| Breastfeeding - Prolactin inhibiting factor Secreted by: Influence PP: | Hypothalamus
Suppresses release of prolactin
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| Breastfeeding - Oxytocin Secreted by: Influence in PP | Posterior pituitary
"Milk ejection" reflex
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| Breastfeeding - Estrogen Secreted by: Influence PP: | Ovary and placenta
Blood levels decrease and initiation of lactation associated
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| Breastfeeding - Progesterone Secreted by: Influence PP: | Ovary and placenta
Blood levels decrease and initiation of lactation associated
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| Breastfeeding - ACTH Secreted by: Influence PP | Anterior pituitary
High level believed necessary for maintaining lactation (milk synthesis and release)
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| Breastfeeding - HPL Secreted by: Influence on PP | Placenta
Not applicable to PP but stimulated mammary growth of alveoli in non pregnant/pregnant state
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| Breastfeeding - Thyroxine Secreted by: Influence on PP | Thyroid
Important in maintaining lactation by control of metabolism; direct effect on mammary glands
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| Breastfeeding - thyroid releasing hormone Secreted by: Influence on PP | Hypothalamus
Stimulates release of PRL; can be used to maintain lactation
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| Breastfeeding - Growth hormone Secreted by: Influence on PP | Anterior Pituitary
may act with prl in initiation of lactation
May act with thyroxine to potentate milk yield; most important in maintaining lactation
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| PP PE Breasts | Observe presence of engorgement, lumps, red streaks
Observe integrity of nipples
Check presence of colostrum or milk
BF women will have glandular hypertrophy
Hyperpigmentation may be permanent
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| PP PE Uterus | Assess position of uterus in relation to pp day
If enlarged or displaced, reevaluate after void
Assess tenderness, and fundus for firmness
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| PP PE Perineum | Lie on side for visualization
Inspect laceration/epis, integrity of sutures,hemorrhoids/hematoma
Perineum edematous and bruise at dx - returns to nl at 2 weeks pp - may remain tender to palpation
suture visible at 6 weeks
Encourage perineal hygiene.
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| REEDA is | Redness, Edema, Ecchymosis, DIscharge, approximation
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| PP PE Lochia | Assess amt, color and odor
Signs of possible problem: lochia malodorous, becomes heavier and bright red; associated with abdominal pain or fever
Bleeding may increase temp. with activity
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| PP PE Bladder | Assess UO, dysuria, ability to void and edema r/t lacerations
birth related trauma usually resolves within 24 hours
Cath may be necessary for distention, increased bleeding or edema interfering with voiding
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| PP PE Extremities (exam of legs) | Place foot flat and knees slightly bent
Palpate both sides of legs for varicosities, calf tenderness and heat
Inspect for edema, redness
Homan's sign
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| PP PE Vital Signs | BP and Pulse Q 15 min X 2 hours after delivery
Temp: slight increase; normal w/i 24 h
Pulse - Normal (>100 indicates infection or hemorrhage)
Resp: Normal 12-20/min
BP: transient rise but should resolve to pre-preg over a few days
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| Rubella immunization | If prenatal titer <1:10 (non immune)
0.5 mL subcutaneously
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| RhoGAM administered to: | Rh negative mom if:
Infant Rh positive
Mother not sensitized to Hr D antibodies
Infant has a negative direct autoagglutination test
-Administer within 72 hours
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| Perineal pain management | Ice packs prn x 24-48 h
Topical anesthetic prn
Witch hazel
Stiz bath, cold or hot
Analgesia (Ibuprofen, acetaminophen, tylenol 3 or percocet)
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| Constipation managment | Common after extended labor and NPO or fear d/t extensive laceration
Docusate sodium 50-100 mg oral qd or bid
increase fluids and fiber
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| Afterbirth pain management and cause | Cause: continuing contraction and relaxation of uterus
More common with increased parity
Triggered by oxytocin
Keep bladder empty
Ibuprofen (anti-inflammatory)
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| Non-lactating breast care: | Pharmacologic agents not recommended by FDA
Moderate to severe pain
Tight fitting bra or ace wrap
Ice
Avoid nipple stimulation
Discourage expression of milk
Mild analgesics
Cabbage leaves
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| Sore nipples Presentation and management | Pink, burning nipples related to nipple stretching, peaks at 3-4 d pp.
Air dry, correct positioning/breaking of suction, apply EBM/colostrum, treat thrush, least sore side first, ice for engorgement/pain relief, apap 30 min before feeding.
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| Cracked nipples Presentation and management | Blistered, scabbed, cracked d/t trauma
Air dry, correct position/breaking of suction, apply ebm/colostrum, treat thrush, least sore side 1st, Ice, apap 30 min prior to feed.
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| Engorgement Presentation and management | Usually temporary, tight, red, shiny skin; occasional fever up to 101, usually pp day 3-5, pain.
Use good bra, facilitate drainage, anti-inflammatory, heat before bf, cold after bf, feed q2h, cool cabbage leaves pump to reduce milk buildup.
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| Low milk supply Presentation and management | infant wt loss >7%, infant with concentrated urine, dry hard stools, lethargy, dry MM
extra feeds/pumps/pump after feed, skin to skin during pump, stop smoking, evaluate mom for endocrine abnormalities, reglan protocol, acupuncture, fenugreek.
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