Postpartum Flashcards by Callie Wanek

The six weeks following childbirth
Dramatic physical and psychological changes as the body returns to pre-pregnancy state
Resolve issues r/t labor & delivery
Adapt to new role as mother

Postpartum

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Oxytocin-hormone responsible for involution and initiation of breastmilk let-down
–breastfeeding aids in faster involution–afterpains: ibuprofen (helps cramping), Tylenol (helps incisional pain), Percocet

Postpartum changes

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returning of the uterus to normal size and position

involution

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Position of uterus--fundal check
– position mother flat on back, bladder
emptied
– support uterus with one hand firmlyplaced just above symphysis pubis,fundus palpated with pinkie side of
other hand

Postpartum changes - involution

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Position measured in relation to
fingerbreadths from umbilicus
 After delivery--fundus at umbilicus or
slightly below
 By 48 hours--2-3 fingers below umbilicus
 If above umbilicus or displaced to one
side--check bladder distention

Involution - fundal check

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Should be firm and about the size of a grapefruit
 If not firm–”boggy”–risk for bleeding.
Perform fundal massage.
 Report if tone becomes boggy after
massaged stopped. May need IV oxytocin
or methergine.
 Teach client self fundal massage

Involution - uterine tone

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stops post partum hemorrhage by constricting blood vessels

Know range of patient’s BP cause it will raise it

Methergine

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1 cause of postpartum hemorrhage

caused by full bladder and cure is voiding

Uterine atony

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Greater than 500 mL for vaginal
 Greater than 1000 mL for C-section
 #1 Cause--uterine atony
 Cervical or vaginal lacerations
 Hematoma--vulvar, vaginal, retroperitoneal
 Retained placenta

Postpartum hemorrhage

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First hour following delivery most critical period
for hemorrhage - worried about uterine atony and lacerations and hemorrhage
Early hemorrhage
– Atony
– Lacerations
– Hematoma
Late hemorrhage
– Retained placenta
– Subinvolution - uterus is tired - at risk for PPH and infection
– Infection

Postpartum hemorrhage (2)

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Vaginal discharge after delivery
 Composed of endometrial tissue, blood,
and lymph
Assess quantity--increases w/ activity
– Heavy--1 large pad saturated w/in 1
hour
– Moderate--less than 6 inches on pad
– Light --less than 4 inches on pad
– Scant--less than 1 inch

Lochia

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Assess type (color)
– Rubra–red, duration 1-3 days, small clots,
fleshy odor
– Serosa–pinkish brown, duration 3-10 days, may
have fleshy odor
– Alba–white, mucus-like, 10-14 days, no odor - continues up to 6 weeks
Report foul odor, large clots, or if color returns to rubra

Lochia color

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Cervix regains muscle tone but never closes as tightly as in pre-pregnant state Regains thickness and normal dilatation
within 12 hours postpartum May feel bumpy, irregularly shaped upon further cervical checks

Cervical changes

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Regains muscle tone gradually

Rugae disappear during labor, reappear 3-4 weeks postpartum

Vaginal changes

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Very tender with or without episiotomy
or laceration
Regains muscle tone in 2-3 weeks if no
episiotomy
Epis heals superficially in 5-6 weeks but
still tender
Deep healing may take 6 months
 Watch for S/S of infection or hematoma

Perineal changes

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Ice pack provides comfort, reduces
swelling
Teach good perineal cares
Topical anesthetics may be used
– benzocaine spray, Tucks pads
Prevent constipation
NO intercourse, tampons, douching

Perineal changes (2)

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Abdominal wall and muscles regain tone
gradually.
May exercise lightly during 6 weeks
– walking, stretching, Kegels
 Blood volume returns to normal in 2 weeks
– 4-6 # weight loss thru diuresis, blood
loss
– Hgb/Hct levels fluctuate

Other changes

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Urethra is sore and edematous
May be difficult to void— epidural
effect or swelling, may need catheter
 Increase fluids to prevent bladder
infections

System changes - urinary

Constipation common due to slowed
peristalsis, poor abdominal muscle
tone, sore perineum, narcotic use
Increase fluid and fiber
Encourage ambulation
Stool softeners--Colace, MOM

GI System

Stretched skin of abdomen gradually regains tone
 Striae remain but become lighter color
May experience increased perspiration
due to hormone changes
 May experience generalized rash

SKin

Vital signs--monitor for hemorrhage
and shock
Lochia usually less in quantity than
vaginal delivery
Fundal checks performed carefully
I &amp; O--usually have Foley and IV first 24 hours post-op

C-Section

heart rate will increase, respiratory will increase, temperature will lower, looks pale and diaphoretic

signs of hemorrhage and shock

Assess for S/S of infection and
separation
Teach bracing with pillow
Teach incision cares

Incision : c-section

common due to
hormones, fatigue, new role, anxiety
– Experienced by 85% of women and resolves
within 2 postpartum weeks
- hormone imbalance and fatigue

Postpartum blues

``` more serious – Occurs between 2 weeks and 3 months PP – listless, withdrawn, mood swings – does not derive enjoyment from baby – still reality based - chemical imbalance and clinical depression treated with hormone replacement therapy, antidepressants (SSRIs), counseling ```

Postpartum depression--

``` very serious, less common – impaired sense of reality – danger to self and baby – need referral to psychiatrist - underlining problem is bipolar and schizophrenia ```

Postpartum psychosis

``` 1ST PHASE OF MATERNAL ADAPTATION DURING WHICH MOTHER PASSIVELY ACCEPTS CARE, COMFORT & DETAILS ABOUT NEWBORN - 1ST 24 HOURS - MORE PASSIVE ```

Taking in

``` 2ND PHASE OF MATERNAL ADAPTATION DURING WHICH MOTHER ASSUMES CONTROL OF HER OWN CARE AND INITIATES CARE OF INFANT NURSING INTERVENTIONS - 24-48 HOURS - MORE ASSERTIVE, BUT WANTS REASSURANCE ```

Taking hold

``` 3RD PHASE OF MATERNAL ADAPTATION THAT INVOLVES RELINQUISHMENT OF PREVIOUS ROLES AND ASSUMPTION OF A NEW ROLE AS A PARENT NURSING INTERVENTIONS - DAY 3-6 - MORE INDEPENDANT - GIVE POSITIVE FEEDBACK ON HER CARE ```

Letting go

``` Most Rh negative women become sensitized in first pregnancy with Rh positive infant – This infant is not at risk – Subsequent Rh positive infants are at risk because their blood is attacked by the maternal antibodies formed in response to exposure to first Rh positive infant ```

Rh sensitization

Rh incompatibility results in fetal hemolytic anemia – Fetal erythrocytes destroyed by maternal antibodies  Results in fetal pathologic jaundice – Fetus compensates by producing immature erythrocytes---erythroblastis fetalis - see in the first 24 hours - the lower the yellow is the higher the bilirubin is - bilirubin is stored in GI so feed them to get rid of meconium

Rh sensitization (2)

Infant may die in utero, or shortly after birth  May require intrauterine transfusion or transfusion following delivery with Rh negative, type O blood.  RhoGAM - prevention only

Rh sensitization (3)

``` More common than Rh incompatibility but causes less severe problems  Occurs if maternal blood type is O and fetal blood type A, B, or AB  Naturally occurring anti-A and anti-B antibodies transfer across placenta to fetus ```

ABO incompatibility

May occur in first born infants  Infant becomes jaundiced – Rarely requires transfusion – Phototherapy generally successful in resolving

ABO incompatibility (2)

``` Production of breastmilk Milk production begins in pregnancy – estrogen – progesterone After delivery estrogen and progesterone levels fall and prolactin increases ```

Lactation

``` Colostrum in the first 3 days  Thick yellow fluid rich in antibodies, proteins, and calories. “Liquid Gold”  Small amount but adequate to meet infant’s caloric needs  Avoid supplementing ```

Lactation (2)

``` Transitional breastmilk “comes in” 3-4 days postpartum Abundant supply may cause engorgement – nurse frequently –Warm packs – ibuprofen 400 mg q 6 hrs Let down reflex-oxytocin stimulates ```

Lactation (3)

``` Mature milk by day 8-10 Thin, watery, bluish--”skim milk” Contains everything needed for nutrition--No supplementation Easily digested, natural laxative Changes composition daily to meet needs ```

Lactation (4)

``` Contains antibodies, baby protected from maternal illness by antibodies produced Nurse at least 10 minutes per side to reach hind milk rich in protein and fats Frequent nursing increases and maintains adequate milk supply – 8-12 feedings in 24 hours Promotes bonding Hormones released during feedings promote maternal sense of wellbeing and contentment ```

Lactation (5)

``` Audible swallowing Mother’s breasts feel less full after feeding BMs--2-5 times QD (by day 3) Voids--4-6 times QD (by day 3) Weight gain 1/2 -1 oz per day, regains birth weight within 2-3 weeks ```

Signs of adequate infant intake

Cradle and cross cradle Football hold Side-lying Sitting

Breastfeeding position

``` Lips flanged Tongue on underside of breast Minimal discomfort if proper latch May apply purified lanolin to nipples Prevent chapping--air dry after feedings, change wet breastpads/bra ```

Proper latch-on

``` L: latch A: audible swallowing T: type of nipple C: comfort of nipple H: hold (positioning) Scored: 0-2 points for each category ```

Latch scoring tool

``` Avoid pumping in 1st 3 weeks Pump just enough to relieve engorgement Try to match infant’s feeding patterns when pumping at work (q 2-3 hours) Store in clean plastic bags or bottles – refrigerator-72hrs, deep freeze 6 months Thaw by immersing in warm water ```

Pumping and storage