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