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Flashcards in post-partum (unit 2) Deck (110)
1

uterus involution

•uterus returns to pre-pregnant size/shape
•causes sharp afterpains (ct.)
•lowers 1 cm/day
•by PP day 10, uterus within pelvis and non palpable
*WNL at 4-6 weeks pp

2

lochia-discharge

•Rubra- birth-PP 3
•Serosa- PP day 4-10
•Alba (yellow)- PP day 11-wk 6

3

Why might a patient
“gush” blood upon
standing up from a
supine position?

•blood may have pooled in the vaginal vault while the patient rested in a supine position
•also have some clots
•As long as the increased flow resolves and the patient’s uterus is firm and ML, she is ok

4

cervix PP

•immediately post SVD, wide enough for hand
•after 1 wk- pencil eraser
•external os from round to slit
•possible lacerations

5

vagina PP

•immediately post SVD- edematous w/ rugae
•after 6 wk- pre-preggo size
•atrophic until menses resumes
•lacerations possible

6

dyspareunia

•dryness and itching of vagina
•r/t declining estrogen levels b/c diminishes lubrication
•esp. common in BF b/c prolactin antagonizes estrogen

7

perineum PP

•edema/bruising
•lacerations (1-4 degree)
•episiotomy
•lacerations

8

1st degree perineal laceration

•extends thru skin/structures to superficial muscles

9

2nd degree perineal laceration

•extends thru muscles of perineal body

10

3rd degree perineal laceration

•extends thru anal sphincter muscle

11

4th degree perineal laceration

•involves anterior rectal wall
•rare
•require more intervention

12

perineum discomfort tx

•ice for first 48 hrs
•then sit baths bid

13

estimated blood loss (EBL)

•lose 500cc blood SVD
•lose 1000cc blood C/S
•also lose blood volume when diaphoresis/diuresis PP
*orthostatic hypotension common

14

what does declining estrogen levels PP cause

•no lubrication of vagina
•diaphoresis

15

why don't mom's go into hypovolumetric shock during delivery?

•blood flow to placenta diverted during delivery
•rapid reduction in uterine size

16

cardiac output PP

•elevation of pulse, SV, and CO for first hr
•gradual decrease to prepreggo
•brady common 1-2 days PP b/c dec. blood volume (trying to maintain CO)
•if tacky check for infection
•baseline by 8-10 wks

17

coagulation PP

•hypercoagulated in pregnancy and PP for 2-3 wks b/c have increased fibrinogen
**risk for DVT for up to 6 months

18

labs PP

•elevated WBC (25,000) for 2 wks
•H&H hard to assess and only addressed if hct <18 and symptomatic
-dizzy
-pallor
-weak

19

GI PP

•constipation
•BM incontinence if operative vaginal birth
•hunger
•thirst
*keep NPO until sounds, then clear liquids until flatus

20

why constipation PP

•inc. progesterone slows peristalsis
•long NPO
•painful BM from trauma

21

why hunger/thirst PP

•long NPO
•large energy expenditure
•early diuresis

22

urinary system PP

•excessive diuresis w/in 2 days (3000cc/day)
•r/o distended bladder d/t
-dec. tone
-trauma
-diuresis
-anesthesia (epidural -> retention)
*high risk for UTI/postpartum hemorrhage

23

musculoskeletal PP

•aches/pains/fatigue
•relaxin WNL w/in few days, but can cause early hip pain
•diastasis recti possible

24

musculoskeletal 6-8 wks PP

•joint return to normal
•feet permanently enlarged
•muscle tone restored b/c progesterone dec.

25

integumentary PP

•melanin dec. -> linea nigra, chloasma fade
•estrogen dec. -> palmar erythema, spider nevi fade
•striae gravidarum fade to silver (never go away)

26

endocrine PP

•menses w/in 4-6 wk (if not BF)
•ovulation before menses so BC crucial
•estrogen, progesterone, HPL, HCG decline
•prolactin decline at 3 wk if not BF
•resolution of GDM

27

why does prolactin delay menses/ovulation

•suppresses the release of LH and FSH
•still need BC

28

what causes lactation

•rapid falling levels of estrogen and progesterone
•increasing levels of prolactin
•increasing oxytocin (let down)

29

weight loss PP

•12 lbs at delivery
•8-9 lbs at 2 wks
•pre-preggo at 6 mo-yr
*BF slower loss of adipose tissue INITIALLY

30

initial PP assessment

•begin 4th stage
•frequent VS, fundus, lochia
•pain
•IV site/patency
•bladder
•LE movement

31

VS 4th stage

•q15min x 4 hr
•q30min x 2 hr
•qhr x 2 hr
•q4-8 hrs

32

BUBBLE HE

•breasts
•uterus
•bladder
•bowel
•Lochia
•Episiotomy
•Homan's sign
•Emotions

33

PP breast assessment

•soft, nontender first 2 days
•firm/lumpy/fuller 72-96 hrs b/c colostrum mature milk
*s/sx fullness subside w/ BF

34

PP uterus assessment

•have pt void first
•massage/expel clots
•provide meds if needed (Pitocin, methergine, cytotec)

35

u/1,2... (u-1,2...)

•fundus below umbilicus
•how many fingers below (subjective)

36

1,2.../u (u+1,2...)

•fundus above umbilicus
•how many fingers above (subjective)

37

problem w/ distended bladder

•uterus elevates to R
•uterus can't ctx/drain
•uterus retains lochia and can cause excessive bleeding
*can't DC if < 30 cc/hr

38

PP lochia

•constant trickle dangerous (MD)
•excessive amnt w/ ctx indicates unrepaired laceration (MD)
•foul smell could be infection (tenderness/temp/tachy)
*goal < 1 pad/hr

39

PP episiotomy/incision assessment

R- redness
E- edema
E- ecchymosis
D- discharge
A- approximation
*indicates infection IF accompanied by pain

40

LE assessment PP

•edema/varicose veins possible
•DTRs should be 1+ or 2+ b/c brisk hyper reflexes indicates pre-eclampsia

41

dec. BP PP could be...

•dehydration
•hypovolemia

42

inc. BP PP could be

•pre-eclampsia
*compare to admission BP

43

tachycardia PP

•could b from excitement, fatigue, dehydration, hypovolemia
•check fundus, lochia, CBC
•may be early s/sx of shock
*brady would be from blood vol. dec.

44

temp. PP

•elevated up to 100.4 expected first 24 hr
•if 100.4 or > for more than 24 hr, notify MD

45

promoting comfort PP

•assess/tx pain
•3000cc fluids/day
•regular diet
•adequate rest/sleep

46

Rhogam PP

•given if mom Rh- and baby Rh+
•given w/in 72 hrs

47

Kleinhauer-Betke

•drawn w/ CBC PP to determine ant of fetal blood in maternal circulation
*if > 15 mL, increase Rhogam

48

MMR vaccine

•all child-bearing should have, esp. if non-immune
•DON'T become preg for 1 month
•Rubella during prig devastating for fetus

49

breast care for lactating mom

•avoid soap/lotion to nipples
•feed baby on demand
•keep nipples dry (pat)
•use lanolin for nipple trauma
•good support bra
•cabbage leaves/ibprofen/ice for engorgement (ONLY BF mom cam pump)

50

kegal exercises PP

•will strenghten perineal muscle
•tighten muscle (stop urine), hold 10 sec, relax
•do 5 times daily

51

PP danger signs to report to MD

•fever > 100.4
•localized breast edema (esp. w/ flu s/sx)
•persistent abd tenderness/pelvic pressure
•persistent perineal pain
•UTI
•lochia change
•DVT s/sx

52

criteria for D/C

•free of infection s/sx
•able to void > 30cc/hr
•fundal ht/lochia WNL
•H&H WNL
•Rhogam/rubella vaccinated
•educated on danger signs
•mom able to reach HCP in emergency

53

bondings

•developed by attachment and physical contact b/t parents and infant
•love and acceptance
•enhanced in 1st hr of life
•maternal touch is key

54

early post-partum hemorrhage

•occurs w/in 24 hrs after delivery
•vaginal: > 500cc blood loss
•C/S: > 1000cc blood loss
•caused by uterine atony or trauma r/t laceration

55

risk factors for PP hemorrhage

•uterine atony
•placental complications
•precipitous delivery
•MgSO4 therapy
•laceration trauma/hematomas
•inversion of uterus
•sub involution of uterus
•retained placental fragments
•coagulopathies (DIC)

56

causes of uterine atony

•overdistention (multi GA; tumor; polyhydranious; big baby)
•multipartiy
•tocolytic drugs (rlx uterus)
•prolonged/precipitous (rapid) labor/delivery
•C/S
•induction

57

signs of early PP hemorrhage

•excessive lochia
•fundus soft/difficult the locate
•fundus above expected level

58

early PP hemorrhage tx

1. fundal massage (tx for uterus)
2. ABCs
3. start new (lg. bore) IV for fluids
4. admin meds/blood
5. elevate legs (tx for shock)

59

meds for early PP hemorrhage

•O2- 2-3 L NC to inc. RBC sat
•oxytocin
•Methergin IM- inc. froce/freq. ctx
-contra in HTN
•carbopropst/cytotec rectal- smooth mscl. ctx
•Hemabate IM
•Hespan- vol. expander (colloid)

60

anticipated action for PP hemorrhage

•OR
•D&C
•uterine packing/Bakri balloon
•hysterectomy
•ICU

61

shock

•complication of early PP hemorrhage
•vasoconstriction -> blood shunted to vital organs (heart, lungs, brain)

62

RN protocol in emergency for PP hemorrhage

•Labs (H&H; T&S)
•pusle ox
•foley
•O2 by ventimask
•add. fld./lines; blood products
*autonomy when MD not present

63

RN initial interventions PP hemorrhage

•call for help
•fundal massage
•bolus Pitocin
•continuous pulse Ox/VS
•reverse trendelenberg
•change pads, so can observe
•calm pt/fam.
•privacy

64

hematoma

•250-500cc of blood collects in tissues in vulvar, vaginal, retroperitoneal area
•may present as bluish mass
•caused by laceration, but occurs behind it
•severe rectal pain/pressure (normally)
•s/sx concealed blood loss
•trauma that can lead to early PP hemorrhage

65

laceration of birth canal

•bright, red bleeding w/ firmly contracted uterus, midline at expected level
•trauma that can lead to early PP hemorrhage

66

late PP hemorrhage

• > 24 hr PP, but less than 2 wks PP
•caused by subinvolution

67

subinvolution

•uterus remains enlarged w/ continued local discharge

68

subinvolution causes

•retained placental fragments
•endometritis (pelvic infection)

69

s/sx subinvolution

•prolonged, foul-smelling, excessive lochia
•hemorrhage
•pelvic pain/heaviness
•backache
•malaise
•fatigue
•large/soft uterus

70

subinvolution tx

•methergine- ctx.
•abx
•D&C last resort when methergine/abx not working

71

thromboembolic disorders PP

•major cause of maternal death
•5x greater occurrence in prig and PP than non-preggo
•3x more likely w/ C/S

72

causes of thrombosis in childbearing women

•venous stasis
•hypercoagulable blood
•vessel injury

73

risk factors for thrombosis

•varicose veins
•smoking
•obesity
•hx of thrombophlebitis
•clotting disorders

74

SVT

•in calf
•swelling/erythema
•tenderness/warmth
•lg hard vein
•pain w/ walking

75

DVT

•little/no s/sx
•calf swelling/warmth/erythema
•tenderness
•pedal edema
•pulses unequal
•venous doppler dx

76

prevention of thrombosis

•ambulation
•range of motion
•avoid pillows under knees

77

SVT tx

•support hsoe
•rest
•analgesics (NO ASA or ibuprofen)
•elevate affected leg

78

DVT tx

•IV heparin
•bedrest
•elevate
•analgesics
•Coumadin
•monitor coags
•gradual ambulation
•DONT massage

79

endometritis

•2-5 days PP
•inflammation/infecton of endometrium
•can spread, causing sepsis and sterility

80

s/sx endometritis

•fever/chills
•tachy
•lethargy
•malaise
•anorexia/nausea
•abd/uterine pain
•foul, purulent lochia

81

endometritis tx

•IV abx
•analgesics
•comfort
•prevention
•high fowlers to drain lochia

82

UTI

•cystitis, urethritis
•dysuria/diuresis
•tx w/ abx and cranberry juice
•300 mL fld./day

83

PP wound infection

•most common PP infection
•episiotomy, vagina, C/S incision
•s/sx of REEDA

84

PP wound infection tx

•I&D (incision & drainage)
•abx
•analgesics
•remove staples/suture
•pack
•sitz bath/warm compress
•freq. peri-care
•inc. flds

85

mastitis

•infection of lactating breast
•doesn't occur w/in first few days b/c skin still in tact and no milk yet
•more common in first BF mom
•one breast ONLY

86

mastitis causes

•bacteria (staph) enter injured nipple
•insufficient breast emptying
•engorgement/stasis

87

s/sx mastitis

•flu-like
•chills/fever/malaise
•HA
•localized red/inflam/tender

88

mastitis tx

•abx
•bedrest initially
•3000cc fld/day
•ice
•analgesics
•BF (safe) unless abscess forms or too painful (pump)
•warm shower (dilation)
•resolves in 24-48 hr
*tx crucial to avoid abscess

89

mastitis prevention

•empty q 2-3 hr
•no tight bra
•massage milk ducts while feeding
•inc. fld intake
•good hygiene

90

baby blues

•1-2 days PP
•rarely last > 2 wks
•trouble sleeping/eating and tearful but not sad
•still joyfully care for baby
•no tx needed

91

PP depression

•4 wks- 6 months PP
•s/sx depression > 2 wks
•persistent sadness/mood swings
•no joy w/ infant care
•tx w/ psychotherapy, meds, ECT

92

PP psychosis

•severe psychotic state
•confusion
•disorientation
•AH &/or VH
•delusion
•obsessive behavior
•paranoia
•self/infant harm
•tx w/ aggressive IN pt hospitalization

93

the bigger/more stressed the uterus...

•the worse the afterpains b/c has to work harder to get back to normal
•d/t
-multiple babies
-big baby
-fibroids (benign tumor)
-uterine problems

94

important RN measures

•check IV and assess what have/should be hanging
•ensure the foley bag below bladder

95

intervention for deviated fundus PP

•help to bathroom
•if can't urinate use running water, warm perineal, hands in water, sitz bath
•in/out cath as last resort

96

lochia assessment PP day 2

•rubra/serous
•scant

97

if hemorrhage from laceration trauma, uterus is...

•firm b/c laceration doesn't involve the uterus, so it would be normal for PP
*firm uterus w/ bleeding is

98

s/sx hypovolumetric shock

•earliest sign is tachycardia
•BP inc. initially, then dec. after ⅓ vol. lost
•RR inc. to get O2 to organs
•skin cool, clammy, diminished cap refill
•pallor
•tachycardia
•hypotension
•N/V
•dec. UOP
*elevate legs

99

causes of concealed blood loss

•broken stitch
•hematoma

100

meaty clots

•from uterine atony

101

thin/shiny clots

•from trauma

102

tocolytic drugs

•MgSO4
•terbutaline

103

trauma causes

•large baby
•operative vaginal delivery
•soft part abnormality
•rapid delivery

104

uterine atony tx

•fundal massage
•bolus Pit.
•meds

105

trauma tx

•call MD
•ice
•pressure
•tx shock if occurs

106

hypovolemic shock tx

•trendelberg/elevate legs
•O2
•2nd IV/fluids
•admin expanders
•ABCs
*both uterine atony and trauma ultimately lead to shock

107

uterine atony last resort tx

•D&C
•hysterectomy
•packing

108

trauma last resort tx

•repair

109

when to start worrying about PP infection

•if > 100.4 w/in first 24 hrs
• if 100.4 or > for more than 24 hrs

110

RN action if pt calls w/ breast pain

•ask if both or one breast
•mastitis is normally just one breast
•engorgement is both