Postpartum: Sherpath

Question 1

Descent of the Uterine Fundus: Three processes

Answer 1

Contraction of the muscle fibers
Catabolic processes
Regeneration of uterine epithelium

Question 2

Subinvolution

Answer 2

is a slower than expected return of the uterus to its non-pregnant size and consistency

Question 3

What may delay the uterus from returning to it pre-pregnancy state?

Answer 3

Retention of placental fragments
Pelvic infection
May not be evident until well after discharge

Question 4

Involution can be evaluated by measuring the descent of the fundus.

Answer 4

About 1 cm per day
14 days after childbirth, the fundus should no longer be palpable.
“After pains” or intermittent uterine contractions, cause discomfort for many women (multiparas, breastfeeding)

Question 5

Bubble Assessment: B (Breast)

Answer 5

Colostrum excretion
Assist mom with putting baby to nipple within first hour of birth
Assist with breastfeeding positions, techniques

Question 6

Bubble Assessment: U (Uterus)

Answer 6

Location of fundus above baseline level
Fundus displaced from midline
Excessive lochia
Bladder discomfort
Bulge of bladder above symphysis
Frequent voidings of less than 150 mL of urine, which may indicate urinary retention with overflow

Question 7

Bubble Assessment: B (Bowel)

Answer 7

Push fluids
Assist to toilet
May need stool aids

Question 8

Bubble Assessment: B (Bladder)

Answer 8

Monitor for distention
Assess for retention
Displaced fundus

Question 9

Bubble Assessment: L (Lochia)

Answer 9

Lochia rubra
Lochia serosa
Lochia alba
Color
Amount, type, and odor
Foul odor suggests endometrial infection

Question 10

Bubble Assessment: E (Episiotomy)

Answer 10

Pericare

Infection prevention

Question 11

Focused Assessment: Perineum

Answer 11

First-degree: Involves the superficial vaginal mucosa or perineal skin.
Second-degree: Involves the vaginal mucosa, perineal skin, and deeper tissues, which may include fascia and muscles of the perineum.
Third-degree: Same as second-degree lacerations but involves the anal sphincter.
Fourth-degree: Extends through the anal sphincter into the rectal mucosa.
Perineum: After childbirth may be edematous and bruised
Episiotomy or trauma
Healing takes up to 4–6 months

Question 12

Focused Assessment: Vagina

Answer 12

It takes 6–10 weeks for the vagina to regain its non-pregnant size and contour

Question 13

Focused Assessment: Fundus and Lochia

Answer 13

Lower extremities
Homan’s sign, +/-
Edema and deep tendon reflexes
Vital signs
Blood pressure
Orthostatic hypotension
Pulse
Respirations
Temperature
Pain

Question 14

Focused Assessment: Periurethral Area

Answer 14

A laceration in the area of the urethra may cause women difficulty urinating after birth. An indwelling catheter may be necessary for a day or two.

Question 15

Focused Assessment: Vaginal Wall

Answer 15

A laceration involving the mucosa of the vaginal wall.

Question 16

Focused Assessment: Cervix

Answer 16

Tears in the cervix may be a source of significant bleeding after birth.

Question 17

Provide Comfort Measures

Answer 17

Ice packs
Sitz baths
Perineal care
Topical medications
Positioning
Analgesics 
Rest

Question 18

Normal Lochia Rubra(1-3 days)

Answer 18

Bloody; small clots; fleshy, earthy odor, red or red/brown

Question 19

Normal Lochia Serosa (4-10 days)

Answer 19

Decreased amount; serosanguineous; pink or brown-tinged

Question 20

Normal Lochia Alba (11-21 days)

Answer 20

Further decreased amounts; white, cream, or light yellow

Question 21

Abnormal Lochia Rubra

Answer 21

Large clots; saturated perineal pads; foul odor

Question 22

Abnormal Lochia Serosa

Answer 22

Excessive amount; foul smell; continued or recurrent reddish color

Question 23

Abnormal Lochia Alba

Answer 23

Persistent lochia serosa; return to lochia rubra, foul odor; discharge continuing

Question 24

Postpartum changes by system: Neurological

Answer 24

Bilateral and frontal headache common due to changes in fluid and electrolyte balance
Spinal headaches due to spinal anesthesia
Blurred vision, photophobia, and abdominal pain may indicate preeclampsia

Question 25

Postpartum changes by system: Cardiovascular

Answer 25

Transient increase in maternal cardiac output after childbirth Excess plasma volume is eliminated by diuresis and diaphoresis Gradually cardiac output decreases and returns to normal in 6–12 weeks increased clotting factors predispose the postpartum woman to clot formation

Question 26

Postpartum changes by system: GI

Answer 26

ecreased food and fluid intake during labor Reduced muscle and bowel tone Fear of pain during defecation First stool 2–3 days post birth

Question 27

Postpartum changes by system: GU

Answer 27

Increased bladder capacity and decreased sense to fluid pressure may result in urinary retention. Stasis of urine allows time for bacteria to grow and can lead to urinary tract infection. The distended bladder displaces the uterus and can interfere with uterine contraction and cause excessive bleeding

Question 28

Postpartum changes by system: Musculoskeletal

Answer 28

First 1–2 days after childbirth, muscle fatigue and aches Abdominal wall: Diastasis recti Reduction in musculoskeletal discomfort: Exercises to strengthen the abdominal muscles Good posture Body mechanics

Question 29

Postpartum changes by system: Integumentary

Answer 29

``` Skin gradually returns to non-pregnant state: Decrease in hormone levels Stretch marks (striae gravidarum) fade: Do not disappear Loss of hair: Normal response to hormone changes Begins 4–20 weeks after delivery Regrown in 6–15 months ```

Question 30

Postpartum changes by system: Endocrine

Answer 30

Hormones: Human chorionic gonadotropin is present for 3–4 weeks Resumption of ovulation and menstruation: Breastfeeding may delay the return of ovulation and menses Ovulation may occur before the first menses Lactation: Prolactin initiates milk production within 2–3 days of the birth

Question 31

Postpartum Weight Changes

Answer 31

Approximately 5.5 kg (12 lbs) is lost during childbirth Fetus, placenta, amniotic fluid Another 4 kg (9 lbs) is lost over the next 2 weeks Another 2.5 kg (5 lbs) is lost by 6 months post delivery Adipose tissue is used for energy expenditure during labor and breastfeeding

Question 32

Postpartum Psychosocial Assessment

Answer 32

Mild depression: “baby blues”, lasts a few days to a couple of weeks PP Affects 70–80% of new mothers PP Depression begins generally in the first week postpartum and can last 6 months or longer, debilitating Should not last longer than 2 weeks Must be distinguished from postpartum depression or postpartum psychosis Panic disorder Tachycardia, shortness of breath Fear of dying or “going crazy” Postpartum obsessive-compulsive disorder Consuming thoughts of harming the baby Posttraumatic stress disorder Women perceive childbirth as a traumatic event

Question 33

Postpartum Psychosocial Assessment: S/S

Answer 33

``` Feelings of sadness, crying Loss of pleasure in usual activities Anxiety, agitation or irritability Feelings of guilt Fatigue, sleep disturbances Difficulty concentrating or making decisions Depression (may not be present at first) Suicidal thoughts ```

Question 34

Early Post Partum Hemorrhage

Answer 34

First 24 hours | Cumulative blood loss of 1000 mL or greater

Question 35

Late Post Partum Hemorrhage

Answer 35

From 24 hour up to 6 weeks postpartum Sub-involution of the uterus Retained placental fragments

Question 36

S/S of Post Partum Hemorrhage

Answer 36

A uterus that does not contract or does not remain contracted Large gush or slow, steady trickle, ooze, or dribble of blood from the vagina Saturation of one peripad per 15 minutes Severe, unrelieved perineal or rectal pain Tachycardia

Question 37

Collaborating with the provider: PPH

Answer 37

Uterine massage Check bladder for distention. Laboratory studies Administer fluids and medication.

Question 38

PREVENTION: PPH

Answer 38

Identify predisposing factors.

Question 39

Hypovolemic Shock

Answer 39

During and after birth, women can tolerate a blood loss approaching that of blood added during pregnancy 1500–2000 mL Compensatory mechanisms maintain the blood pressure so that vital organs are perfused Shock occurs with excessive blood loss

Question 40

Uterine Atony: Manifestations

Answer 40

Fundus is difficult to locate “Boggy” or soft feel to the fundus Becomes firm when massaged Excessive lochia and clots

Question 41

Uterine Atony: Management

Answer 41

Measures to contract the uterus | Provide fluid replacement