Postpartum Flashcards
Review postpartum complications, fundal and lochia changes, breastfeeding, and physical changes. (109 cards)
1
Q
Immediate complication
What are 2 life-threatening postpartum complications of cesarean section?
A
Bleeding and Infection
2
Q
Immediate complication
How many saturated pads per hour is considered hemorrhage?
A
- > than 1 pad per hour or
- one pad that gets saturated within 15 minutes
3
Q
Immediate complication
How much blood loss is considered hemorrhage for a vaginal delivery and a cesarean delivery?
A
- Vaginal delivery: > 500 mL after delivery
- Cesarean delivery: > 1000 mL after delivery
4
Q
How should pads be measured for postpartum hemorrhage?
A
- weigh pad before and after use
- note time in between pad changes
5
Q
Interventions:
Postpartum hemorrhage
A
Interventions for postpartum hemorrhage:
- uterine massage
- empty pt bladder
- measure pads
- give oxytocin as ordered
- monitor VS, I&O, O2 sat, LOC
- contact provider if it doesn’t resolve
- pad count (weigh/keep)
- Keep IV patent, give IV bolus as ordered
- anticipate possible transfusion
- draw labs as ordered (CBC, type and crossmatch, coagulation studies)
6
Q
What maternal temperature is considered normal during the first 24 hours after birth?
A
98.6o - 100.4o F (36o - 38o C)
7
Q
Interventions:
Postpartum infection
A
- assess vital signs
- get cultures of blood, sputum, or lochia
- antibiotics
8
Q
What are the normal assessment findings for the fundus on day one after delivery?
A
The fundus should be firm, midline, and at the umbilicus.
9
Q
How far down should the fundus decrease per day?
A
The fundus should decrease 1 cm downward per day.
10
Q
What are the interventions if the fundus is boggy or NOT midline?
A
- have the client urinate
- gently massage the fundus until firm
11
Q
What is lochia?
A
Lochia is vaginal discharge after pregnancy.
12
Q
Describe:
Lochia rubra
A
The first vaginal discharge that is red that occurs from birth of baby to about 2-3 days postpartum.
13
Q
Describe:
Lochia serosa
A
The second vaginal discharge that is brownish-pink or brown that occurs from 3 - 10 days postpartum.
14
Q
Describe:
Lochia alba
A
The third vaginal discharge that is yellow to white in color that occurs from about 1-2 weeks postpartum.
15
Q
Describe abnormal postpartum lochia that indicates infection.
A
- a very bad odor
- yellow/green/gray in color
16
Q
When do postpartum clients start ovulating again?
A
Postpartum clients can start ovulating soon after birth even without having their period yet and while breastfeeding.
Teach clients about contraceptives to prevent pregnancy too soon.
17
Q
What is colostrum?
A
Colostrum is the first milk that comes in for breastfeeding:
- birth to about 3 days
- thick, early creamy milk
- full of vitamins, minerals and proteins
- contains immunoglobulins and antioxidants
18
Q
What is engorgement?
A
Engorgement is when the breasts are very full of milk
It can be painful and uncomfortable for the mother.
19
Q
What are the interventions for engorgement if the client will not be breastfeeding?
A
- cabbage
- wear a snug bra (binder no longer recommended)
- apply ice packs
- analgesics
20
Q
When will engorgement resolve?
A
About 36 hours after it started.
21
Q
What is the correct way a newborn should latch onto a breast?
A
Newborn mouth should be over entire areola
22
Q
How long should a breastfeeding baby feed for each breast?
A
Baby feeds on each breast for 15 - 20 minutes.
A breastfeeding session would last between 30 and 40 minutes.
23
Q
How often should moms breastfeed a newborn?
A
Breastfeed newborns every 2 - 3 hours.
24
Q
How often should caretakers bottle feed a newborn?
A
Bottle feed a newborn every 3 - 4 hours.
25
If a newborn has to breastfeed every 2 hours and the client started breastfeeding at 1 PM. **When would the next breastfeeding session start?**
The next breastfeeding session would start at **3 PM**
## Footnote
*Start at the time of when the client started breastfeeding, not when it ended*
26
How does the mom **break the suction** from a breastfeeding baby?
Break the breastfeeding suction by **inserting a finger between the mouth and the breast.**
27
How **long** is breastmilk or formula the only food given to the baby?
Breastmilk or formula is **the only food for 4 - 6 months**.
## Footnote
*Nothing else should be given up until that time.*
28
Can breastfeeding mothers take **medications**?
When breastfeeding, all medications and over-the-counter medications need to be **approved by the HCP first** before taking.
29
What are the **complications** of breastfeeding?
* cracked nipples
* mastitis
30
What are the **interventions** for cracked nipples?
* no soap (dries out the skin)
* expose breasts to air for part of the day
* use different breastfeeding positions for baby
* apply lanolin (emollient)
31
# Describe:
Mastitis
Mastitis is an **infection of the breast with clogged milk ducts.**
32
# Interventions:
Mastitis
* heat or cold packs (to decrease inflammation)
* supportive bra (no wire bras - too much constriction)
* still breastfeed or pump every 4 hours
* antibiotics (doxycycline, cephalexin - Keflex)
* rest
* increase fluid intake
* pain meds (ie. ibuprofen)
33
# Medications:
Mastitis
* analgesics
* antibiotics
34
What are the general **assessments** postpartum**?**
**Assess for:**
* bleeding
* infection
* pain
* perineal hematoma
* incision for cesarean delivery
* depression
* DVT (thrombophlebitis)
* fundal height
35
What are the general **interventions** postpartum?
* vital signs
* intake and urinary output
* encourage fluids/fiber/walking
* pain relief
36
What are the specific **assessments and interventions** for the **renal** system postpartum?
1. assess urine output
2. may have retention if anesthesia was used
* encourage urination or straight cath
## Footnote
*Client will have frequent urination to get rid of extra fluids.*
37
What are the specific **assessments and interventions** for the **gastrointestinal** system postpartum?
1. assess for constipation
* encourage fluids/fiber/walking
* stool softeners
2. give extra 500 calories per day due to breastfeeding
3. multivitamin for deficiencies
38
What are the specific **assessments and interventions** for **mental health** postpartum?
1. assess for postpartum depression
* therapeutic communication, possible group therapy, and medications
2. assess for mom/baby bonding
39
What are the specific **assessments and interventions** for the **cardiac** system postpartum?
Assess for **DVT** (thrombophlebitis) and **pulmonary embolism**
## Footnote
*Provide life-saving interventions and notify HCP*
40
What are the specific **assessments and interventions** for **pain** postpartum?
Assess for pain
* ice packs to perineum
* sitz baths
* analgesics
* suppositories if client had episiotomy
41
BUBBLEHE
B- Breasts
U - Uterus
B - Bladder
B - Bowel
L - Lochia
E - Episiotomy/Perineum
H - Hemorrhoids
E - Emotional Status
42
What are **normal** assessment findings postpartum?
* Takes time for uterus to go back to normal
* Abdominal cramps = normal - uterus shrinking back to pre-pregnancy size - esp when baby is breastfeeding
* Normal to pass large amounts of urine during the first few days because the body is getting rid of extra fluid from pregnancy - blood focused to uterus now has to recalibrate
* The first BM may not occur for 2-3 days due to hormones, medications, dehydration, fear and decreased physical activity → Norco – causes constipation (education opportunity)
* Hair loss is not unusual. Normal growth cycle will return but could take 6-15 months
43
What are some **abnormal** postpartum assessment findings?
* Soaking more than 1 pad/hour
* Foul smelling discharge
* Fever of 100.4 F or higher
* Severe HA, excessive swelling, visual disturbances
* Incisional separation or pain that will not go away
* No BM within 4 days
* Urination problems (frequency, burning, discomfort, hematuria)
* Pain, warmth, tenderness in legs (calf area)
44
What are some **high-risk** postpartum complications that can occur?
1. hemorrhage
1. early
2. late
2. infection
1. endometritis (high risk w/C-sections)
2. UTI
3. mastitis
3. thromboembolitic disease
1. PE
2. DVT
4. psychiatric problems
1. postpartum blues
2. Postpartum Depression
3. Postpartum psychosis
45
What are the **"4 T's"** of postpartum hemorrhage?
The Four T's mnemonic can be used to identify and address the four most common causes of postpartum hemorrhage:
1. Tone (uterine atony)
2. Trauma (laceration, hematoma, inversion, rupture)
3. Tissue (retained tissue or invasive placenta)
4. Thrombin (coagulopathy)
46
How is post-partum hemorrhage (PPH) **defined?**
Worldwide, postpartum hemorrhage is the leading cause of pregnancy related deaths (approximately 140,000 women die each year due to PPH)
It is:
* \>500 mL blood loss following a vaginal delivery
* \> 1000 ml blood loss following a cesarean delivery
* OR 10% drop in Hematocrit (HCT) from pre-delivery baseline
* OR PP hemodynamic instability (abnormal/unstable BP, HR, arrhythmia etc. )
* OR PP blood transfusion needed
47
What are some **risk factors** for post-partum hemorrhage?
* Uterine atony is a very common cause for Early PPH
* Over distension of the uterus (macrosomic baby, multiple gestation, polyhydramnios)
* Exhaustion of uterus muscle (long labors, medicines that cause uterus to relax ie. mag)
* Use of medications which cause the uterus to relax
* Placenta problems (placenta acreta, abruptio)
* Lacerations and hematomas
* **Previous history** of PPH doubles or triples the risk of a repeat occurrence
48
What are the **clinical signs** of post-partum hemorrhage?
* Boggy uterus (hard to find)
* Saturating a peri pad within one hour
* multiple clots expressed during fundal massage
* Decreased Blood pressure
* Increased heart rate
* Decreased urinary output/oliguria (shunt from kidneys first --\> oligo)
* Extreme thirst
* restlessness
* constant oozing, trickling of bright red blood from vagina
* skin pale, cool, clammy,
* dizzy/lightheaded
49
What are the **lab tests** for PPH?
* Hgb and hct
* Coagulation profile (PT)
* Blood type and crossmatch
50
What are the **nursing interventions** for post-partum hemorrhage? Why?
* VS
* Assess source of bleeding
* Fundal height, position, firmness-massage
* Assess lochia-color quantity and clots (size)
* Signs of bleeding-lacerations, episiotomy, or hematoma
* Assess bladder for distension
* Insert an indwelling catheter
* Maintain/initiate IV fluids with isotonic solution (LR, NS)
* Administer o2
* Elevate Legs
* Blood transfusion
51
What are the most common risk factors for **Early Post-partum hemorrhage?**
uterine atony, lacerations of perineum
52
What are some **first-line** treatments for post-partum hemorrhage?
1. Controlled traction on umbilical cord w/prolonged 3rd stage \>30 min
2. uterine massage after birth
3. administration of Oxytocin after delivery of placenta (IM or IV)
***These 3 interventions can prevent 50% of PPH****.*
53
What are **second line meds** for PPH?
* Methylergonovine (methergine)
* Carboprost (hemabate)
* Misoprostol (cytotec)
54
What are some other treatments for PPH?
* Manual removal of retained placental fragments by Health care provider
* Uterine Tamponade
* Bakri Balloon
* Uterine Artery Embolization
* Surgical Management - Last resort is a hysterectomy
55
Define early PPH vs. late PPH
early: after birth up to 24 hours
late: 24 hours - 6 weeks postpartum
56
What are the main causes for early PPH and late PPH?
Early: uterine atony, lacerations
Late: retained placenta
57
What are lacerations a potential cause of and when do you suspect it?
Another factor in Early PPH: lacerations of the cervix, vagina or perineum
Suspect lacerations if the uterus is firm and bright red bleeding persists
58
What are **hematomas** and when would you suspect them?
* Injury to a blood vessel from birth trauma or inadequate hemostasis at the site of repair of an incision or laceration
* Patients will often have severe pain
59
What is the **treatment** for a hematoma?
* Ice packs and analgesia
* Small ones resolve on their own (\< 3cm and not expanding)
* Large ones and ones that are expanding require surgical intervention
60
Describe late PPH.
* Most frequently due to subinvolution or retained placental fragments
* Lochia fails to progress from rubra to serosa to alba normally
* Lochia serosa that persists for longer than 2 weeks may be suggestive of subinvolution
* Placental fragments must be removed!
61
What are the **nursing interventions** for PPH?
* Uterine massage
* Empty the patient’s bladder
* Oxytocin as ordered
* Monitor VS, I&O, O2 sat, LOC
* If not resolved quickly, contact Health care provider
* Pad count (weigh or keep)
* Keep iv patent, give iv bolus as ordered but anticipate possible transfusion
* Draw labs as ordered (CBC, type and Crossmatch, coagulation studies…)
62
Define **postpartum endometritis.**
* Infection of the uterine lining
* Associated with childbirth
63
What are the risk factors **PP endometritis**?
* Cesarean birth (had uterus opened up)
* Chorioamnionitis
* Pprom
* Compromised health status (ie. immunosupression, anemia)
* Manual removal of placenta (doctor can introduce bacteria)
* Diabetes mellitus
* Anemia
64
What would you find on **assessment** for pp endometritis?
* uterine tenderness on palpation
* foul smelling lochia
* tachycardia
* chills
* fever
65
What is the **treatment** for pp endometritis?
* IV abx
* if fever persists after 48 hours, keep testing
66
How is **pp cystitis defined** and what are the **risk factors**?
* Lower urinary tract infection, Typically caused by E. coli
* Trauma to Urinary tract
* Urinary retention
* Contamination during catheterization
67
How do we **prevent** and **treat** pp cystitis?
* Keep bladder empty during labor and postpartum period - good for them to get up and walk
* Avoid catheterization if possible but Use careful aseptic technique when you must do it
* Clean catch specimen for Culture & sensitivity (C&S) if infection suspected
* Antibiotics to treat
68
Define **pp mastitis.**
* Infection of the interlobular connective tissue of lactating women
* Onset typically between 2-8 weeks after delivery
69
What are the **s/s** of pp mastitis?
* Warm, reddened, painful area on the breast
* Fever, chills, headache, flu-like aches and malaise (tiredness, discomfort)
* can have bright yellow milk
* can lose supply if severe
70
How can you **prevent** pp mastitis?
* Handwashing before breastfeeding
* Supportive but non-constricting bra
* Frequent and complete emptying of breast milk - feed q2hrs
* Avoid trauma to nipples
* Learn correct latch technique
* Keep nipples dry between feedings
71
How do you treat **pp mastitis?**
* **Keep breastfeeding**
* Antibiotics (ie. doxycycline, cephalexin - Keflex)
* Rest
* Increased fluid intake
* Warm or ice packs - open draining wound, probably cold, whatever makes them feel comfortable
* Pain medications such as ibuprofen (b/c antiinflammatory)
72
Define **thromboembolic disease** and common types seen pp.
Blood clots (often DVT or PE)
73
What are the main **causes** of thromboembolic disease?
* Venous stasis
* hypercoagulability
* injury to epithelium of blood vessel
74
What are the **risk factors** of thromboembolic disease?
* Cesarean birth (12 hours in bed post c-section)
* Prolonged immobility
* Obesity
* Smoking
* Varicose veins
* diabetes
75
What are the s/s of a DVT?
* Leg pain/tenderness (but not always)
* Unilateral swelling, warmth, redness
* Calf tenderness
76
What are the s/s of a PE?
* Apprehension/anxiety
* Pleuritic chest pain (severe, not heart)
* Dyspnea
* Tachypnea
* Hemoptysis
* Peripheral edema
* Distended neck veins
* elevated temp
* Hypotension
* Hypoxia
* Diaphoresis
77
What is the tx of a DVT?
* Immediate administration of anticoagulants
* Heparin or Low molecular weight heparin
* Maintenance with warfarin is started at 1-5 days
* Strict bed rest and elevation of affected limb are required
* Once symptoms have subsided, ENCOURAGE walking (Have patient wear support Hose but NOT when there are symptoms)
* Do not massage affected extremity
* Measure the leg circumferences
* Administer analgesics (NSAIDs)
78
What is the tx of a PE?
* Bedrest
* Place client in semi fowler’s position
* Administer o2 by mask
* Anticoagulant therapy
* Other medications that may be used
* Thrombolytic therapy -Alteplase (activase), steptokinase (Steptase)
79
What meds are used to break up a PE (thrombolytic therapy)?
* Alteplase (activase)
* steptokinase (Steptase)
80
What are the 3 pp psychiatric disorders and what is their incidence/timeline?
1. Postpartum Blues
* The mildest of the three
* Also known as “Adjustment Reaction with depressed mood”
* Or “baby blues”
* Occurs in as many as 85% of mothers
* Typically begins 2-4 days after delivery and resolves within 10-14 days
2. Postpartum depression
* Also known as “Peripartum major mood episodes”
* Occurs in 10-20% of all PP women
* Typically begins about 4th week after delivery but can occur anytime in the first year
3. Postpartum psychosis
* Most serious of the three
* Also known as “Postpartum mood episodes with psychotic features”
* Occurs in 1-2 per 1000 women
* Symptoms usually show up within a few days of delivery
* considered an emergency
81
What are the **3 phases** of psychologic adjustments for new moms?
1. Taking in (2-3 days)
* Preoccupied with own needs, passive, dependent
* Touches and explores infant
* Needs to discuss her L&D experience
2. Taking hold (3-10 days)
* Obsessed with body functions, initiates self care
* Rapid mood swings
* Responds to instruction about infant care and self care
3. letting go (10 days - 6 weeks)
* Mothering functions have been established
* Sees infant as a unique person
82
What are the **s/s** of postpartum blues?
* Mood swings
* difficulty sleeping
* anorexia
* a feeling of letdown
83
What are the **risk factors** of pp blues?
* changing hormone levels
* pain
* fatigue
* an unsupportive environment or insecurity
84
What should you do to **encourage** mothers experiencing pp blues?
Positive reinforcement of good behaviours
85
What are the **s/s** of pp depression?
* Similar to symptoms of postpartum blues but PERSISTS
* Feelings of worthlessness
* Lack of interest in usual activities
* Lack of concern over personal appearance
* Irritability or hostility toward baby
* Thoughts of suicide
86
What are the **risk factors** of pp blues?
* History of depression prior to pregnancy
* History of bipolar disorder
* Stressful life events
* Lack of social support or a stable life partner
* Loss of newborn
* First pregnancy or young mother
87
What is the **tx** of pp depression?
1. Individual or group therapy, plus…
2. Antidepressants (some are bf safe)
1. Selective serotonin reuptake inhibitors (SSRIs)
2. Tricyclic antidepressants
88
What are the **s/s** of postpartum psychosis?
* Sleep disturbances
* Depersonalization\*
* Confused, irrational
* Hallucinations, delusions
* Psychomotor disturbances:
* Stupor
* Agitation
* rapid and incoherent speech
89
What are the **risk factors** of pp psychosis?
* History of previous postpartum psychosis
* History of bipolar disorder
* Family history of either condition above
90
What is the Tx of pp psychosis?
* Keep mom and baby safe!
* inpatient psychiatric care
* Antipsychotic medications
* Psychotherapy
* Social support
91
What are the nursing interventions for psychological issues?
* Observe patient with the baby, by herself, with her family and friends
* Review history
* Note adequacy of coping skills
* Note degree of self-esteem
* Recognize early signs of problems
* Support positive parenting behaviors
* Discuss patients plans for baby and self
* Refer to social services if necessary
92
What are the **3 types of lochia** and when are they seen?
1. Lochia rubra, \<3 day pp and should not recur
2. Lochia serosa, 3-10 days pp
3. Lochia alba, 1-2 weeks pp
93
What are **abnormal findings** pertaining to lochia?
* lochia "going backwards"
* bright red for a long time after delivery
* clots bigger than egg/golf ball
* \*note that C-sections will have less bleeding dt uterus being "cleaned"
94
How do you assess the **breasts** pp?
* Determine if breast or bottle feeding
* inspect for redness or engorgement
* inspect for fissures, cracks, inversion
* Palpate lightly for softness
* slight firmness dt filling
* tightness can be engorgement (usually 3-4 days pp)
* warmth or tenderness?
95
What is pt teaching for **breastfeeding** moms?
* Use supportive bra
* Keep nipples dry and watch for fissures or cracks\*
* Watch for reddened or tender spots on breast - mastitis, or plugged duct (has to be massaged and emptied to avoid mastitis)
* Additional teaching during breastfeeding attempts as needed
96
What is pt teaching for non-breastfeeding moms?
* Use supportive bra
* Avoid breast stimulation
* Apply cold packs
* Apply cold, raw cabbage leaves inside bra
97
What are **normal vs. abnormal finding**s of the uterus pp?
* Palpate the position of the fundus in relation to the umbilicus
* Is fundus firm or boggy?
* Is fundus in midline? - ask if they’ve voided. If it’s not midline, may indicate full bladder. Have them void first (documentation ex: U-2)
* Inspect abdominal incision for patients with a cesarean delivery using REEDA mnemonic
* Excessive pain may indicate infection
98
What does the REEDA mneomic stand for when assessing an incision/laceration?
R-Redness
E-Edema
E-ecchymosis
D - discharge/drainage
A - approximation
99
What is patient teaching for uterus pp?
* fundal position
* firmness
* how to massage fundus
* C-section fundus -sore
100
What are assessment **findings/interventions** for bladder pp?
* Assess bladder for distension frequently due to postpartum diuresis - 2-3 hours = need to void
* Assess frequency, burning or urgency
* A boggy uterus, displaced uterus or palpable bladder is a sign of bladder distension
* Catheterization may be needed if distension is noted and patient can not void
101
What will you teach the pt about **bladder** to encourage voiding?
* Out of bed - even if c section
* Ambulation helps them feel better
* Helps pass gas
* helps them heal fast if c-section
* Pouring warm water on perineum
* Running water in the sink (to mimic sound of urine flow)
* Encourage relaxation and breathing
* Encourage frequent voiding
* Increase the amount of water she drinks - they forget to drink
102
What would you look for when assessing bowels?
* Bowel movements normally return within 2-3 days after childbirth
* Constipation can increase pressure on sutures and increase discomfort, but won't pop out sutures if pt has a laceration
* bowel sounds - can be hypoactive
* Is pt passing gas?
* med - Colace/ docusate sodium
103
What do you need ot teach the pt about bowels/BM?
* Help re-establish normal bowel pattern
* Encourage ambulation
* Encourage fluids
* Encourage fresh fruits/vegetables/fiber in diet
* Stool Softeners
* Don’t be afraid!
104
How should you assess lochia?
* Have pt lay on side and bend knee and look from back (hemorrhoids can be checked this way too)
* Assess for character, amount, odor and clots
* If it smells, indicative of infection
* Assess for Rubra, Serosa, and Alba
* Clots and heavy bleeding may be caused by uterine relaxation, retained placenta fragments or an unknown cervical laceration
* Sample charting:
* “Scant lochia rubra on pad, no unusual odor noted, no clots expelled during fundal massage.”
105
What would you teach the pt about lochia?
* Inform patient of the normal changes with color and characteristics
* Effect of position changes
* Dizziness, gush of fluid when getting up
* Hygienic measures
* Wipe front to back, peri bottle, pat dry
* Peri bottle should have clean water
* Patients who have a Cesarean birth may experience less bleeding
106
How do you assess the **perineum**?
* Inspect Perineum area for REEDA
* R- Redness
* E- Edema
* E- Ecchymosis (Bruising)
* D- Discharge (Drainage)
* A- Approximation (of wound edges)
* Sample charting: “Perineum intact.”
107
What do you teach the pt about the **episiotomy/peri area**?
* Discuss the type of episiotomy or laceration patient has (4 degrees)
* Sutures will dissolve on own
* Ice packs
* Sitz Baths - seat and can sit perineum in water
* Peri bottle after voiding and BM
* Kegel exercises
* Topical sprays or foam for pain control - numbing foam
108
How do you assess **hemorrhoids?**
* Patient in sims -same time as lochia/peri
* Tucks pads, warm water
* Note the size, number and pain or tenderness
* Sample charting:
“One pea-sized hemorrhoid noted, non-tender.”
109
What would you teach the pt about **hemorrhoids?**
* Care - tucks pads, warm water, witch hazel, preparation H
* Pain management
* Discussion regarding what they are and what future implications may be involved
* Sometimes they come back or don’t go away
