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post-partum (unit 2) Flashcards

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1
Q

uterus involution

A

•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

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2
Q

lochia-discharge

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

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

A
  • 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
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4
Q

cervix PP

A
  • immediately post SVD, wide enough for hand
  • after 1 wk- pencil eraser
  • external os from round to slit
  • possible lacerations
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5
Q

vagina PP

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

dyspareunia

A
  • dryness and itching of vagina
  • r/t declining estrogen levels b/c diminishes lubrication
  • esp. common in BF b/c prolactin antagonizes estrogen
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7
Q

perineum PP

A
  • edema/bruising
  • lacerations (1-4 degree)
  • episiotomy
  • lacerations
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8
Q

1st degree perineal laceration

A

•extends thru skin/structures to superficial muscles

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9
Q

2nd degree perineal laceration

A

•extends thru muscles of perineal body

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10
Q

3rd degree perineal laceration

A

•extends thru anal sphincter muscle

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11
Q

4th degree perineal laceration

A
  • involves anterior rectal wall
  • rare
  • require more intervention
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12
Q

perineum discomfort tx

A
  • ice for first 48 hrs

* then sit baths bid

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13
Q

estimated blood loss (EBL)

A

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

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14
Q

what does declining estrogen levels PP cause

A
  • no lubrication of vagina

* diaphoresis

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15
Q

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

A
  • blood flow to placenta diverted during delivery

* rapid reduction in uterine size

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16
Q

cardiac output PP

A
  • 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
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17
Q

coagulation PP

A

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

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18
Q

labs PP

A 
•elevated WBC (25,000) for 2 wks
•H&H hard to assess and only addressed if hct <18 and symptomatic
-dizzy
-pallor
-weak
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19
Q

GI PP

A

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

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20
Q

why constipation PP

A
  • inc. progesterone slows peristalsis
  • long NPO
  • painful BM from trauma
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21
Q

why hunger/thirst PP

A
  • long NPO
  • large energy expenditure
  • early diuresis
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22
Q

urinary system PP

A 
•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
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23
Q

musculoskeletal PP

A
  • aches/pains/fatigue
  • relaxin WNL w/in few days, but can cause early hip pain
  • diastasis recti possible
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24
Q

musculoskeletal 6-8 wks PP

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

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