Postpartum Physiological Adaptations Flashcards
(99 cards)
1
Q
What is the average length of time for return to non-pregnant physiology?
A
6 weeks
2
Q
What are the most significant risks during postpartum period?
A
Hemorrhage, infection, shock
3
Q
Why are uterine contractions important after delivery?
A
Minimize bleeding
4
Q
Define afterpains
A
Uncomfortable uterine cramping after delivery
5
Q
What happens to estrogen after delivery?
A
It drops
6
Q
Effects of decreased estrogen in PP
A
Breast engorgement (increased PRL), diaphoresis, diuresis, less vaginal lubrication
7
Q
What happens to progesterone after delivery?
A
It drops
8
Q
Effects of decreased progesterone PP?
A
Increased body muscle tone
9
Q
What happens to blood glucose after delivery & why?
A
It drops due to decreases in placental enzyme insulinase
10
Q
What happens to hCG after delivery?
A
It disappears quickly but can be detected up to 4 weeks PP
11
Q
When does ovulation return in breastfeeding persons & why?
A
About 6 months PP due to suppression by PRL
12
Q
What maintains PRL levels in breastfeeding persons?
A
Breastfeeding frequency, length of feeds, supplement use, infant suck
13
Q
When does ovulation resume in non-breastfeeding persons?
A
7-9 weeks w/ menses resuming by 12 weeks
14
Q
What are important components of PP assessment? (5)
A
VS, uterine firmness, uterine location relative to umbilicus, uterine position relative to midline, amount of vaginal bleeding
15
Q
VS monitoring PP
A
BP, HR q15mins for first 2 hrs
Temp q4hrs for first 8 hrs, then at least q8hrs
16
Q
BUBBLE: focused PP assessment
A
Breasts
Uterus - fundal height, uterine placement, consistency
Bowels & GI function
Bladder function
Lochia - color, odor, consistency, amount (COCA)
Episiotomy - edema, ecchymosis, approximation
*Also VS, pain, education
17
Q
PP labs
A
Urinalysis, CBC (Hgb, HCT, WBC, platelet), Rubella titer, Rh status (if unknown)
18
Q
Uterine involution
A
Rapid reduction in uterus size & return to pre-pregnant state
19
Q
What enhances uterine involution?
A
Uncomplicated birth, complete expulsion of placenta/membranes, breastfeeding, early ambulation
20
Q
How does breastfeeding enhance uterine involution?
A
Stimulates exogenous oxytocin release
21
Q
Uterine subinvolution
A
Involution does not happen properly
22
Q
Risk of improper uterine involution
A
PP hemorrhage
23
Q
Uterine exfoliation
A
Healing of placenta site, important part of involution
24
Q
What causes uterine involution?
A
Contractions
25
How do you assess uterus PP?
Cup uterus above symphysis pubis and palpate fundus
26
PP uterine assessments
Fundal height
Uterus location/position
Uterine consistency
27
How much does the fundal height change per day?
About 1 cm per day (one fingerbreadth)
28
Where should the fundus be 1 hour after delivery?
Umbilicus
29
When should the uterus no longer be palpable PP?
About 2 weeks
30
What should you do if the fundus is boggy?
Gently massage it in a circular motion
*If it doesn't become firm, continue massaging and notify provider
31
How do you document PP fundal height?
Reference point = umbilicus (at umbilicus = UU)
Above umbilicus = number before U (e.g. 2 cm above = 2U)
Below umbilicus = number after U (e.g. 2 cm below = U2)
32
Where is the fundus and what does it feel like immediately after delivery?
1-2U and like a grapefruit
33
What can enhance involution/after pain?
Multiparas due to repetitive stretch of myometrial fibers
Overdistended uterus - multifetal, LGA, polyhydramnios, retained clots
Breastfeeding due to higher oxytocin
34
When does involution/after pain typically begin to subside?
By 3rd day = mild discomfort
35
Nursing interventions for involution/afterpain
Analgesics - ibuprofen, narcotics if necessary; facilitates milk ejection/letdown
Position changes --> prone w/ blanket under abdomen/pelvis
Heat
36
Lochia
Uterine debris ejected after birth
37
Typical lochia changes
```
Birth - bright red
1-3 days - rubra (dark red)
4-10 days - serosa (pink, brown-tinged)
11-21 days (up to 6 weeks) - alba (white, cream, light yellow)
6+ weeks - clear
```
38
What causes fundal bogginess?
Uterine atony
39
What can cause uterine atony?
Blood clots, retained placenta
40
Why is it important for the birthing person to void after birth?
Bladder distention can displace uterus and stimulate atony
41
Assessment of PP lochia
Scant - 1 inch stain
Small - <4 inch stain
Moderate - 4-6 inch stain
Heavy - >6 inch stain or saturated in 2 hrs
Saturated - saturated peripad in <1 hr
42
Manifestations of abnormal lochia
Spurting of bright red blood from vagina
Numerous large clots w/ excess blood loss
Foul odor (infection)
Persistent heavy lochia rubra in early PP period beyond day 3 (retained placenta)
Continued serosa or alba beyond normal timeframe (endometritis)
43
Cervical changes PP
Internal os closes, soft, external os may remain slightly open (1 cm) & slit-like
Potential edema, bruising, small lacs
44
Vaginal changes PP
Rugae reappear by 3-4 weeks
Edema resolves by 6-10 weeks
Mucosa thickens w/ return of estrogen production
Muscle tone never fully restored
Dryness, atrophy, dyspareunia more likely in breastfeeding persons
45
Nursing interventions for perineal tenderness, lac, episiotomy
Keep stools soft
Comfort measures - cold for edema/pain, hot packs, sitz bath
Non-opioids, NSAIDs, opioids (PCA)
Topical anesthetics (benzocaine spray, witch hazel)
Squeeze bottle w/ warm water or antiseptic solution to clean area
46
Why can birthing persons tolerate substantial blood loss during birth?
Hypervolemia during pregnancy
47
CV changes PP
Initial increase in CO then return to normal pre-labor values in 1 hr, then decrease to pre-pregnancy level by 6-12 weeks
Plasma volume normalizes via diuresis, diaphoresis
Blood values - leukocytosis during labor & immediately PP; normalizes by 6 days PP
Increased plasma fibrinogen increases clot risk for 4-6 weeks PP
48
BP changes PP
Typically minimal, transient increase
If low, possible hemorrhage
If high, possible PP HTN
Orthostatic hypotension possible for 48 hrs PP
49
Puerperal bradycardia
HR as low as 40 bpm, common
Assess tachycardia
50
Fever PP
Normal to elevate to 100.4F for 24 hours
If >24-48 hrs, possible infection
51
GI changes PP
Increased hunger, thirst
Constipation due to progesterone - spontaneous BM may not occur for 2-3 days, may anticipate discomfort
Normal BMs by 8-14 days
Flatulence may cause abdominal discomfort
Hemorrhoids may be present
52
Urinary Tract changes PP
Diminished urge to void
Rapid bladder filling (diuresis) - risk for retention, distention, UTI
Stress incontinence - usually improves by 3 months PP; kegels help
*Straight caths preferred if needed
53
Nursing assessments of urinary tract PP
Ability to void
Bladder elimination pattern
Bladder distention --> can displace fundus/uterus
Frequent voiding <150 mL --> retention w/ overflow
54
MSK changes PP
Decreased relaxin --> joints/ligaments normalize
Increased muscle tone as progesterone decreases
Diastasis recti resolves w/in 6 weeks --> recommend gentle exercises to strengthen
55
Neurologic changes PP
Bilateral, frontal headaches common first week due to changes in fluid/electrolyte balances; relief w/ Tylenol/ibuprofen; if not, assess for preeclampsia
Spinal headache --> after spinal anesthesia, relief when supine, may need blood patch
Monitor for preeclampsia
56
When can ovulation resume for breastfeeding persons?
8 weeks to 18 months, average 6 months
57
Weight loss PP
10-12 lb at birth
9 lb over first 2 weeks
Adipose tissue lost slower; 6-12 months to reach pre-pregnancy weight
58
Typical hospital stays PP
Vaginal --> 1-2 days; more frequent assessments closer to delivery
C/S --> 2-4 days (3 nights), post-op pts
59
Important labs to review from prenatal record in PP period
GBS status, HepBsAg status, syphilis screen
60
Immune system review PP
Rubella titer - if negative/low ==> subq rubella or MMR vaccine
Rh - Rhogam at 28 weeks & 72 hrs PP
Varicella - if not immune, vaccine before discharge & 2nd dose 4-8 weeks
Tdap - before discharge or ASAP in PP period if not previously received
61
PP Assessment Schedule (varies)
q15m for 1 hour, then
q30m for 1 hour, then
q1h for 2 hours, then
q4h for 24 hours, then
q8h until discharge
62
Breasts PP
Colostrum secretion at 12 weeks and 2-3 days PP
Milk secretion 3-5 days PP
Changes - tenderness, engorgement, color, nipples (everted, flat, inverted), trauma, mastitis
63
What should DTRs be PP?
1-2+ (mostly normal)
64
Important orders needed in EHR before discharge
Breast pump, contraception, narcotics, home visits
65
Four traditional positions for breastfeeding
Football, Cradle, Modified Cradle, Side-lying
66
Comfort measures PP
Ice packs - reduce edema via vasoconstriction; 12-24 hrs after birth
Sitz baths - cool for first 12 hrs, warm after 24 hrs
Pericare - warm squeeze bottle, pat
dry
Aromatherapy - anxiety, nausea, pain
Acetaminophen, ibuprofen, narcotics
Topicals - witch hazel
67
Breastfeeding education
Wash hands prior
Wear well-fitting bra w/o underwire
Allow on demand nursing (8-12 times in 24 hrs)
Offer second breast before completion; start w/ different breast each time
Drink adequate fluids, proper nutrition/caloric intake
68
Relief of breast engorgement
Warm shower, warm compress before feeding to promote letdown & milk flow
Empty each breast completely each feeding, pumping if necessary
Cool compresses after feedings (seaweed leaves)
69
Nipple care during breastfeeding
Breast creams - Lanolin
Breast shells for irritation, cracking
Flat/inverted nipples --> breast shell between feedings
Sore nipples --> apply small amount of milk to nipples, air dry
70
Education for persons not planning to breastfeed
Lactation suppression --> continuous use of well-fitting, supportive bra for 72 hrs PP
Avoid breast stimulation, warm water on breasts for prolonged periods until lactation ceases
Engorgement --> cold compresses, 15m on, 45m off; cold cabbage leaves in bra
Mild analgesics/NSAIDs for pain/discomfort
71
Exercises for PP birthing person
Pelvic tilt
Kegels
No abdominal exercises for C/S persons for 4-6 weeks
72
Caloric needs of lactating persons
Extra 450-500 kcal/day
73
Caloric needs of non-lactating persons
1800-2200 kcal/day
74
How long should birthing persons take prenatal vitamins PP?
6 weeks
75
What should a PP person do if bleeding occurs?
If it increases, rest and call if continues
76
Important referral resources for PP persons
```
Lactation consultant
Homecare visits
Public health RNs
PT
Early parenting classes
Community support groups
```
77
Sexuality changes PP
Nothing in vagina for 6 weeks
Dryness common --> may need lubricant from 6 weeks to 6 months (oil, silicone, Vit E, coconut oil), vaginal moisturizers
Milk letdown may occur w/ orgasm
Decreased libido common initially for first 3 months
78
Contraception PP
Non-hormonal or progesterone only is safe
No OCPs until milk production established (6 weeks)
IUDs can be placed during C/S or after placenta delivers OR at 6 week PP visit
No E2 containing CPs due to increased clot risk
Non-hormonal options --> condoms, lactational amenorrhea, cervical cap/diaphragm, sterilization (essure, tubal ligation, hysterectomy, vasectomy)
79
Infant breastfeeding benefits
```
Decreased risk of allergies
Infection protection
Decreased risk of DM, asthma, respiratory infections, sepsis, meningitis, ear infections, GI infections, UTIs, obesity, cancer, SIDS, mortality
Meets nutritional needs
Easily digested, well absorbed
Constipation less likely
Less likely to overeat
Not affected by water supply
```
80
Breastfeeding person benefits
```
Oxytocin --> involution, bonding
Less blood loss --> delayed return of menses
Delayed ovulation
Reduced cancer risk
Enhances rest
Convenient, economical
Fewer healthcare costs for infant
Less work missed
```
81
Lactogenesis I
Begins during pregnancy through early PP days
82
Lactogenesis I composition
Colostrum - thick, yellow, high protein, vitamins, minerals, IgA; establishes normal flora in neonate GI tract; laxative effect for first meconium
83
Lactogenesis II
2-3 days PP
84
Lactogenesis II composition
Transitional milk - gradual change over 10 days
Decreased IgA, protein
Increased fat, lactose, calories
85
What hormones are important for breastfeeding?
Prolactin - stimulates milk production
Oxytocin - milk letdown/milk ejection reflex
86
When is most milk produced?
During infant suckling
87
What makes the most milk available?
Increased demand w/ frequent & longer nursing
*If colostrum/milk not removed from breast, negative feedback slows production due to decreased PRL
88
Should pumping be done to relieve engorgement?
No, amplifies problem
89
Lactogenesis III
Mature milk - bluish, thinner, 20 kcal/oz
IGs and antibacterial components present
90
Breast milk make-up
Proteins - easily digested, some passed to stool
Carbs - lactose mainly, improves Ca absorption, energy for brain growth
Fats - half of calories in milk; highest in hindmilk for weight gain; vision, brain, NS development
Vitamins - A, E, C, low D; 400 IU for infant w/in first few days; other water-soluble vitamin content depends on breastfeeding person's intake
Minerals - Fe lower than formula but absorbed 5x as well; breastfed infants maintain Fe stores for first 6 months of life
Enzymes - pancreatic amylase & lipase
Immune components - leukocytes, IGs, secretory IgA
Milk content doesn't change much w/ breastfeeding person's diet except for vitamin levels
91
Reasons for formula feeding
Keeping breasts sexual
Little experience w/ breastfeeding
Partner/family doesn't support breastfeeding
Medication use, condition for unsafe breastfeeding
Poor milk supply
Infant won't latch
Unfavorable past experiences
Work environment doesn't support breastfeeding
Cultural influences
92
When should feedings be stopped?
When infant is non-nutritive sucking
93
Why should bottle feeding and pacifiers be avoided when breastfeeding?
Can cause 'nipple confusion'
94
What indicates a latch problem?
Cheek dimpling, smacking, clicking --> sucking on tongue or nipple only
95
How do you assess sucking?
Gloved finger in infant mouth
96
Engorgement Interventions
Cold packs between feedings
Heat just before feedings
Massage before & after to stimulate letdown
Express/pump a little milk before feeding to soften breast
Feed more often
Wear well-fitting, supportive bra
Pain meds for comfort
97
Nipple pain interventions
```
Ensure proper latch
Vary infant position
Avoid soap - dries nipples
Begin feeding on less sore side
Nipple shields
Lanolin, hydrogel
Expose to air between feedings w/ milk applied
Return to clinic if concern for yeast infection (burning, itching, stabbing, infant thrush)
```
98
Flat, Inverted Nipple Interventions
Roll nipples
Breast pump to make more erect
Nipple shield
99
Breast Milk Storage Guidelines
Countertop (RA) - <4 hrs
Refrigerator - <4 days
Freezer - best is 6 months, up to 12 months (depletes leukocytes)
-thaw in fridge or under warm water; can be kept in fridge for up to 24 hours
Unfinished milk should be used or discarded w/in 2 hrs
