Chapter 17: Postpartum Physiologic Adaptations Flashcards
(139 cards)
1
Q
Involution
A
The rapid reduction in the size of the uterus and return to pre-pregnant state.
2
Q
Exfoliation
A
Scaling off of dead tissue
3
Q
How does the placental site heal?
A
Exfoliation of the post delivery decidua allows healing of the placenta site.
Is an important part of involution.
4
Q
When does involution begin?
A
Begins immediately after delivery of the placenta when the uterine muscle fibers contract firmly around maternal blood vessels at the area where the placenta was attached.
5
Q
Why is contraction of uterine muscle fibers important in involution?
A
- Controls bleeding from the area left denuded when placenta separated.
- As muscle fibers contract, the uterus decreases in size and gradually regains it’s former contour and size.
6
Q
Uterine Involution depends on what three processes?
A
- Contraction of muscle fibers
- Catabolism
- Regeneration of uterine epithelium
7
Q
Uterine Involution: Catabolism
A
The enlarged muscle cells ofthe uterus undergo catabolic changes in the protein cytoplasm -> leading to reduction in individual cell size.
8
Q
What happens to the products of catabolism during involution?
A
It goes through the blood stream to be excreted in urine as nitrogenous waste.
9
Q
What happens during regeneration of the uterine epithelium?
A
- Outer portion of the endometrial layer is expelled with the placenta.
- Within 2-3 days, the remaining decidua separates into two layers.
- The first layer is superficial and is shed in the lochia.
- The basal layer containing the residual endometrial glands remains intact to provide the source of new endometrium.
10
Q
When does regeneration of the endometrium occur?**
A
Regeneration of the endometrium, except at the site of placental attachment, occurs by 16 days after birth.
11
Q
How long does it take for healing at the placental site to occur?**
A
Occurs slowly and requires approximately 6 weeks.
12
Q
How is the placental site regenerated?
A
New endometrium is generated at the site from the sides and from glands and tissue that remain in the lower layer of the decidua after separation of placenta.
13
Q
Where is the location of the uterus within 6-12 hours after childbirth?
A
At the level of the umbilicus
14
Q
How much should the uterus decline each day?
A
One finger breadth per day or 1 cm
15
Q
After birth, the uterus needs to remain
A
Firm and midline
16
Q
What can cause the uterus to rise and become boggy?
A
If blood collects and forms clot within the uterus (uterine atony)
17
Q
How can the uterus rid itself of remaining debris after birth?
A
Through discharge called lochia.
18
Q
What factor can determine whether involution is progressing normally?
A
Location of the uterine fundus determines if involution is progressing normally.
19
Q
Characteristics of the uterus immediately after delivery
A
- About the size of a large grapefruit or softball
- Weighs approximately 1000 g (2.2 lbs)
20
Q
When does the fundus of the uterus descend into the pelvic cavity?
A
By the 14th. Not able to palpate at this point.
21
Q
What can slow the process of uterine involution?
A
Normally slower when the uterus was distended during pregnancy with more than one fetus, a large fetus or hydramnios.
22
Q
When the process of involution does not occur properly, what can happen?
A
Subinvolution can occur.
23
Q
Subinvolution can cause
A
Postpartum hemorrhage.
24
Q
How is descent document?
A
- Is document in relation to the umbilicus.
- For example, U-1 indicates that the fundus is palpable about 1 cm below the umbilicus.
25
Within one week, what should the weight decreases to about
500 g (1 lb)
26
At 6 weeks, the uterus weighs
60-80 g (2-3 oz), which is roughly prepregnancy weight (uterus of multipara may be slightly heavier)
27
Lochia Rubra
- Reddish or red-brown vaginal discharge that occurs immediately after childbirth.
- Composed mostly of blood. Also contains mucus.
28
Lochia serosa
- Pink or brown-tinged vaginal discharge that follows lochia rubra and precedes lochia alba.
- Composed largely of serous exudate, cervical mucus, blood and leukocytes.
29
Lochia alba
- White, cream colored or light yellow vaginal discharge that follows lochia serosa.
- Occurs when the amount of blood is decreased and the number of leukocytes is increased.
- Also contains cervical mucus and fat.
30
When does the amount of blood decrease?
By the fourth day when leukocytes begin to invade the area, as they do any healing surface.
31
When is lochia alba present?
Present in most women until the third week after childbirth but may persist until the end of the 6th week.
32
What is the normal total amount of lochia?
250 mL
33
How is lochia documented?
Use terms such as scant, light, moderate, heavy, excessive.
34
Lochia: Scant Amount
Less than 2.5 cm (1 inch) stain on the peripad
35
Lochia: Light Amount
2.5-10 cm (1-4”) stain
36
Lochia: Moderate Amount
10-15 cm (4-6”) stain
37
Lochia: Heavy Amount
Saturated peripad in 1 hour
38
Lochia: Excessive Amount
Saturated peripad in 15 minutes
39
Lochia flow after c-section
Is less because some of the endometrial lining is removed during surgery.
40
When is lochia flow heavier?
- Immediately after delivery.
- When mother first gets out of bed or after sleeping (d/t gravity which allows blood that pooled in the vagina during hours of rest to flow freely when she stands)
41
Why do some women have a sudden, short episode of bleeding at 7-14 days after birth?
Occurs when the eschar over the placental site sloughs.
42
Bleeding that lasts longer than ___________ should be reported to the HCP.
2 hours
43
Postpartum Afterpains
Intermittent uterine contractions.
44
Postpartum Afterpains are worse in what women?
Multiparas d/t repeated stretching of muscle fibers which leads to loss of muscle tone and ends with repeated contraction and relaxation of the uterus.
45
What can cause severe afterpains in a primipara?
-If her uterus has been overdistended by multifetal pregnancy, a large infant, hydramnios or if retained blood clots are present.
46
Afterpains are particularly severe during
Breastfeeding.
This causes the release of oxytocin from the posterior pituitary to stimulate the milk-ejection reflex and stimulates strong contraction of uterine muscles.
47
What can be used to lessen the discomfort of afterpains?
- Ibuprofen (given with food to decrease nausea/irritation)
- Percocet
- Toradol
48
What is contradicted with the administration of Toradol?
Motrin/ibuprofen!
49
Promotion of Perineal Comfort and Healing includes
· Ice packs
· Topical agents
· Perineal care
50
Relief of hemorrhoids discomfort may include:
· Sitz baths
· Topical anesthetic ointments/sprays
· Rectal suppositories* or ointment (steroids for edema)
· Witch hazel pads (Tucks)
51
What are the benefits of pain relief such as comfort and relaxation?
It facilities the milk-ejection reflex.
52
What position do mothers find keeps the uterus contracted and provides relief?
Lying in prone position with a small pillow or folded blanket under the abdomen.
53
Hypervolemia during pregnancy
Allows the woman to tolerate substantial blood loss during pregnancy without ill affect.
54
About how much blood is lost during vaginal and cesarean deliveries?
Vaginal delivery: Up to 500 mL
| C-Section: Up to 1000 mL
55
Postpartum: Maternal Cardiac Output
Despite blood loss, a transient increase in maternal cardiac output occurs after childbirth.
56
What causes the maternal cardiac output to increase postpartum?
1. An increased flow of blood back to the heart when blood from the uteroplacental unit returns to the central circulation.
2. Decreased pressure from the pregnant uterus on the vessels.
3. The mobilization of excess extravascular fluid into the vascular compartment.
57
How long does the rise in cardiac output, caused by an increase in stroke volume, persist for?
Persists for about 48 hours after childbirth.
58
When does cardiac output return to normal non-pregnant levels in most women?
By 6-12 weeks after childbirth.
59
Changes in maternal plasma volume postpartum
The body rids itself of excess plasma volume needed during pregnancy by diuresis and diaphoresis.
60
Diuresis
Increased excretion of urine.
61
What causes diuresis in postpartum women?
- Facilitated by a decline in aldosterone, which is increased during pregnancy to counteract the salt-wasting effect of progesterone.
- As aldosterone production decreases, sodium retention declines and fluid excretion accelerates.
- A decrease in oxytocin level, which promotes reabsorption of fluid, also contributes to diuresis.
62
What is a normal urinary output in postpartum women?
3000 mL per day is common, especially on days 2 through 5 postpartum.
63
Diaphoresis
Profuse perspiration; rids body of excess fluid
64
Changes in coagulation in postpartum women
Although fibrinolysis increases shortly after delivery, elevations in levels of clotting factors continue for several days or longer, causing a continue risk of thrombus formation.
65
When does hemostasis returns to normal non-pregnant?
It takes 4-6 weeks.
66
How can thrombus formation be prevented in postpartum women?
- Sequential compression devices
| - Ambulation
67
Changes in WBCs in postpartum women
- WBC count increases to as high as 30,000/mm3 during labor and immediate postpartum period.
- Average increase is to 14,000-16,000.
68
When does WBC count fall to normal values after birth?
By 6 days after birth
69
What accounts for the major increase in WBCs after delivery?
Neutrophils, which increases in response to inflammation, pain and stress to protect against invading organisms.
70
When should hematocrit return to normal limits?
Within 4-6 weeks, unless excessive blood loss has occurred.
71
What is common GI problem in postpartum women?
Constipation
72
What are five causes of constipation in postpartum women?
1. Bowel tone and gastric motility, which were diminished during pregnancy as a result of progesterone, remains sluggish for several days.
2. Relaxation of the abdominal wall increases constipation and distention with gas.
3. Restricted food and fluid intake during labor.
3. Perineal trauma, epiostomy and hemorrhoids cause discomfort and interfere with effective bowel elimination.
4. Women may anticipate pain when they attempt to defecate and are unwilling to exert pressure on the perineum.
5. Women taking iron have an added cause of constipation.
73
When does the first stool usually occur in postpartum women?
2-3 days
74
Normal patterns of bowel elimination usually resume by
8-14 days after birth.
75
If the fundus is higher than expected on palpation and is not in midline, the nurse should suspect
Bladder distention
76
What is the average time for non-nursing mothers to resume menstruation is
7-9 weeks after childbirth, although this varies widely.
77
Menstruation that occurs in the first 6 weeks occurs without
Ovulation
78
When does ovulation usually return?
Within 6 months
79
The return of ovulation and menstration in the breastfeeding mother
Is delayed and relates to how long breastfeeding occurs.
80
The length of the delay in menstruation and ovulation depends on several factors including:
- The frequency of breastfeeding (if more often = delay)
- Use of supplements (fewer supplements = delayed ovulation and menstruation)
- Duration of lactation
81
Effect of Oxytocin on Lactation
Necessary for milk ejection or “let-down”.
| Causes milk to be expressed from the alveoli into the lactiferous ducts during suckling.
82
What hormone initiates milk production?
Prolactin
83
Once milk production is established, it continues because of
Frequency suckling by the infant and removal of milk from the breast. (The more the infant nurses, the more milk the mother produces)
84
Postpartum Nursing Assessment Includes
1. V/S
2. Lung sounds
3. Breasts
4. Abdomen & Fundus
5. Lochia
6. Perineum-REEDA
7. Lower extremities (Homans, edema, DTR’s)
8. Elimination
9. Nutrition
10. Pain
11. Incision site/dressing
12. IV site
85
Patient teaching after a cesarean secretion
- Encourage to turn, cough and deep breath every 2 hours while awake
- Include leg exercise, early ambulation
- Avoid carbonated beverages, ice, and straws
- Splint abdomen on small pillow to reduce incisional discomfort when coughing.
86
If mothers receive narcotics for postoperative pain relief, it is important for the nurse to assess what?
Respirations; must be assessed frequently because narcotics depress the respiratory center.
87
If a woman receiving epidural narcotics has a respiratory rate of 12-14 breaths per minute or less, the nurse should:
- Notify the anesthesiologist immediately
- Elevate the HOB to facilitate lung expansion and instruct woman to breathe deeply
- Administer oxygen, and apply a pulse oximeter.
- Follow facility protocol to administer narcotic antagonists
- Observe for recurrence of respiratory depression.
- Recognize that Naloxone reduces the level of pain relief
88
What are signs of paralytic ileus (lack of movement in the bowel)?
- Abdominal distention
- Absent or decreased bowl sounds
- Failure to pass flatus or stool
89
REEDA
Used to assess for signs of infection.
| Stands for redness, edema, ecchymosis, discharge and approximation.
90
Optimal positions after c-section
- Semifowlers (decreases pressure on abdomen)
| - Position on left side as it promotes gas to rise from descending colon
91
How can you provide comfort for a postpartum woman?
- Place a pillow behind her back and one between her knees to prevent strain and discomfort when lying on side.
- Physical care (such as oral hygiene, perineal care, sponge bath, clean linen)
92
After 24 hours, several normal functions return in postcesarean women including:
- Both indwelling catheter and IV infusion are usually discontinued
- Dressing, is removed and often staples removed before discharge.
- Mother is helped to ambulate and is comfortable to sit in a chair for brief periods.
- Clear liquids may be changed to a soft or regular diet when bowel sounds are audible or woman is passing flatus.
93
Abdominal distention is a major source of discomfort. Measures to prevent and minimize it include:
- Early and frequent ambulation
- Tightening and relaxing of the abdominal muscles
- Avoidance of carbonated beverages and the use of straws, which increase the accumulation of intestinal gas.
- Pelvic lifts
- Simethicone
- Rectal suppositories (help stimulate peristalsis and passage of flatus)
94
Simethicone
Help disperse upper GI flatulence
95
Relevant information that is pertinent to determine if there are factors that increase the risk of complications during the postpartum period include:
- Gravida, para
- Time and type of delivery
- Presence and degree of episiotomy or lacerations
- Anesthesia or medications
- Significant medical and surgical hx (i.e diabetes, HTN, heart disease)
- Medications given during the labor or delivery or routinely taken and the reasons for use
- Food and drug allergies
- Chosen method of infant feeding
- Condition of the baby
96
Rh(D) immune globulin may be necessary if
The mother is Rh-negative and baby is Rh-Positive and the mother is not already sensitized.
97
If a mother is not immune to rubella,
Rubella vaccine is recommended after childbirth to prevent her from acquiring rubella during subsequent pregnancies, when it can cause serious fetal anomalies.
98
After being given the rubella vaccine, women are advised not to
Become pregnant for at least 28 days after receiving the vaccine
99
What are risk factors that increase the risk of hemorrhage and infection in postpartum women?
- Grand multiparity (five or more)
- Overdistention of the uterus (large baby, twins, hydramnios)
- Precipitous labor (<3 hours)
- Prolonged labor
- Retained placenta
- Placenta previa or abruptio placentae
- Induction or augmentation of labor
- Administration of tocolytics to stop uterine contractions
- Operative procedures (i.e c-section)
- Infection
- Multiple cervical examination
- PROM
- Manual extraction of placenta
- Diabetes
- Catheterization
- Anemia
100
What are adverse effects of the rubella vaccine?
Transient stinging at the site, fever, lymphadenopathy, arthralgia and transient arthritis
101
If the fundus is difficult to locate or is soft or “boggy”, the nurse must
- Stimulate the uterine muscle to contract by gently massaging the uterus.
- The non dominant hand must support and anchor the lower uterine segment if massaging an uncontracted uterus is necessary (prevents inversion of the uterus).
102
The uterus can continue to contract only if
It is free of intrauterine clots
103
Excessive lochia in the presence of a contracted uterus suggests
Lacerations of the birth canal.
| The health care provider must be notified so that the lacerations can be located and repaired.
104
Normal odor of lochia
Is fleshy, earthy and musty.
| Foul odor suggests endometrial infection.
105
Absence of lochia
May indicate infection.
106
Perineal wound: if redness is accompanied by excessive pain or tenderness, it may indicate
The beginning of localized infection.
107
Frequent voiding of less than 150 mL suggest
Urinary retention with overflow.
108
Signs of an empty bladder include
A firm fundus in the midline and a nonpalpable bladder.
109
Signs of bladder distention include
- Palpable bulge that feels like a soft, moveable mass above the symphysis pubis.
- Upward and lateral displacement of the uterine fundus
- Increased lochia.
110
When the mother can void at least ______________, the bladder is usually empty.
300-400 mL
111
Subjective symptoms of urgency, frequency or dysuria suggest
UTI
112
Breasts should be examined if woman chooses to formula feed because
Engorgement may occur despite preventive measures.
113
The skin of the breasts should be inspected for
Dimpling or thickening, which, although rare, can indicate a breast tumor.
114
The areola and nipple should be carefully examined for potential problems such as
Flat or retracted nipples, which may make breastfeeding more difficult.
115
Signs of nipple trauma such as redness, blisters or fissures
May be noted during the first days of breastfeeding.
116
The breasts should be palpated for
Firmness and tenderness, which indicate increased vascular and lymphatic circulation that may precede milk production.
117
The breasts may feel
Lumpy as various lobes begin to produce milk.
118
Indications of thrombophlebitis include
Localized areas of redness, heat, edema and tenderness.
119
In thrombophlebitis, pedal pulses
May be obstructed sand should be palpated with each assessment.
120
Positive Homan’s sign
Presence of discomfort or redness, tenderness or warmth in the calf with sharp dorsiflexion of the foot.
121
A negative homan’s sign
Absence of discomfort in calf
122
A positive homan’s sign indicates
Deep vein thrombosis
123
Deep tendon reflexes in postpartum women
Should be 1+ or 2+.
| Brisker than average and hyperactive reflexes (3+ to 4+) should be reported.
124
Brisker than average or hyperactive reflexes can suggest
Preeclampsia
125
Common measures to promote relaxation of the perineal muscles and stimulates the sensation of needing to void include:
▪. Medicating the woman for pain to help her relax
▪ Running water in the sink or shower, placing the mother's hands in warm water, and pouring water over the vulva
▪ Encouraging urination in the shower or sitz bath
▪ Providing hot tea or fluids of choice
▪ Asking the mother to blow bubbles through a straw
126
Stasis of urine in the bladder predisposes the woman to UTI. Therefore the mother must be catheterized if:
▪. She is unable to void.
▪ The amount voided is less than 150 mL, and the bladder can be palpated.
▪ The fundus is elevated or displaced from the midline.
127
Women should be encouraged to drink how much fluid each day?
2500 mL
128
Immediate postpartum period
The first 24 hours after delivery
129
Early postpartum period
The first week after delivery
130
Late postpartum period
The second to sixth weeks
131
How does ice help perineal discomfort?
Causes vasoconstriction and is most effective if applied soon after the birth to prevent edema and to numb the area.
132
Perineal care consists of
Squirting warm water over the perineum after each voiding or bowel movement.
133
Anesthetic Sprays
Decrease surface discomfort and allow more comfortable ambulation.
134
Anesthetic Spray instructions
Hold the nozzle of the spray 6-12 inches away from body and direct it toward perineum.
135
Sitting measures in postpartum women
- Squeeze buttocks together before sitting and lower weight slowly onto her buttocks (prevents stretching of the perineal tissue and avoids sharp impact on traumatized area)
- Sitting slightly on the side is also helpful to avoid full weight from resting on episiotomy site.
136
Sitz baths
Provide continuous circulation of water, cleansing and comforting the traumatized perineum.
137
Sitz baths: cool water
Reduces pain caused by edema and be most effective within first 24 hours
138
Sitz bath: warm water
Increases circulation, promotes healing and may be most effective after 24 hours.
139
Vaginal exam findings reveal a slitlike opening of the cervix. What is the correct interpretation of this finding with regard to obstetric history?
Client has a history of pregnancy
