pp care + complications

Question 1

VS changes

Answer 1

Temp elevated (100.4) up to 24 hr then afebrile, can also be elevated 24 hr after milk production
BP elevated then normal
Bradycardia 6-10 days

Question 2

VS changes - abn

Answer 2

High BP: preE, essential htn or chronic, renal issues, anx
Treat with procardia, labetolol, aldomet; MgSO4 IV (2g/hr for 24-48 hr, at least 24)
Tachy: hard labor and birth, hemorrhage; rule out infection
Marked tachypnea: resp disease, pulmonary edema
Temp > 100.4: infection

Question 3

CV changes

Answer 3

CO decrease 30% in 2 wk -> normal by 6-12wk
D/t diuresis (first few days): decrease ECF and weight loss
Failure to do this = pulmonary edema and heart problems (crackles in lungs)

Question 4

Respiratory changes

Answer 4

Lungs clear, non labored
Eupnea: tachypnea = fever, pain; bradypnea = resp compromise, med, anesthesia
Watch for fluid overload: bolus, pitocin, MgSO4

Question 5

Neuro changes

Answer 5

HA: most common complaint, fluid shifts 1st week after, leakage of CSF d/t epidural or spinal (blood patch), chronic or gestational htn, preE, stress and fatigue (rest)
Visual: spots, blurring, bright lights
Treat = caffeine, acetaminophen

Question 6

Nutrition changes

Answer 6

Increase Fe (supplement depending on EBL), may need to continue prenatal vit
Breast feed: increase 300kcal
Non breast feed: decrease 200kcal

Question 7

Lab value changes

Answer 7

Non patho leukocytosis in 1st week (wbc = 25000 - 30000)
EBL: 2-3% hct = 500mL
Plasma = prepreg state in 4-6 wk PP
Plt normal by 6 wk
Blood values = prepreg state by week 6

Question 8

Ovulation/menstruation

Answer 8

Non breast feed: o = 70-75 days; m = 7-12wk
Breast feed: m = delayed 3+ mo (exclusive or not), not birth control (can ovulate without bleed)

Question 9

Weight change

Answer 9

Decrease 10-12 lb (baby, placenta, amniotic fluid
PP diuresis = 5lb
May return to prepreg by 6-8 wk depending on diet and exercise

Question 10

PP assessment

Answer 10

Breasts
Uterus/abdomen
Bowel
Bladder
Lochia
Episiotomy, lacerations, abd incision

Homan’s sign
Emotions

Question 11

PP assessment - breasts

Answer 11

Size and shape, abn, red areas, enlarge, fullness d/t milk
Nipples: cracks, fissures, soreness, inversion
how is feeding going? observe, praise and guidance, prevent issues (+ non breastfeeding)
blocked duct = hard in one area -> massage while feeding, heat before, empty with each feed

Question 12

Non lactating - suppress

Answer 12

Well fitting bra or ace wrap binder, cold compress or cabbage leaves, anti inflam meds, no warm water on breasts, no stim

Question 13

Lactation

Answer 13

Feed q1.5 - 3hr (8-12x/day)
10-20 min each breast (not as long on 2nd)
Heavy ok; not read, hard, sore
No OH 2hr before nursing, only occasional use (pump and dump)
Cradle position, modified cradle, football hold (c/s), side lying (c/s, dont fall asleep), stomachs flush, feed horizontally not from angle above
Good latch = fish shape mouth (shouldn’t head smacking -> break latch, stroke chin to open mouth more, upper lip flared up lower flared out)
Nipple shield = flavor non aggressive feeder
Allow nipples to dry to prevent breakdown

Question 14

Concerns about breast feeding

Answer 14

Pain (nipple tenderness -> poor latch), embarrassment, feel tied down, unequal responsibilities (dads left out)
Getting enough milk: edges of mouth, 6-8 wet diapers/day, swallow, softer breasts; s/s = soft breast, audible swallowing
7 days = 1BM with each feed

Question 15

Breast feed difficulties - insufficient milk

Answer 15

6-8 diapers, increase fluid intake to 2L/day

Question 16

Breast feed difficulties - sore nipples

Answer 16

Good latch, lanolin cream, express breast milk and let dry (open to air), begin nursing on less sore side

Question 17

Breast feed difficulties - flat nipples

Answer 17

Roll with fingers, use shield

Question 18

Breast feed difficulties - plugged ducts

Answer 18

Freq nursing, change positions, manual massage, warm compress, pump, start on affected side (aggressive baby), prevent!, mastitis
Pressure from purse strap, infant sling, car seat belt can cause recurring

Question 19

Mastitis

Answer 19

Sudden onset, chills, fever, malaise, red, painful, swollen areas, possible drainage, unilateral
Warm compress and analgesics, 7-10 days abx (pcn), take all!, supportive bra all the time to avoid milk stasis (no underwire), HH, prompt attention to blocked ducts, good positioning and latch, supply and demand, report flu like S, regular complete emptying
continue to breastfeed!!

Question 20

Mastitis - milk stasis

Answer 20

Failure to change infant position to allo emptying of all lobes
Failure to alternate breasts at feedings
Poor suck
Poor let down

Question 21

Mastitis - bacteria

Answer 21

Poor HH
Improper breast hygiene
Failure to air dry breasts after breastfeed
Use of plastic lined breast pads that trap moisture against nipple

Question 22

Mastitis - breast/nipple trauma

Answer 22

Incorrect positioning for breastfeeding, poor latch, failure to rotate position on nipple, incorrect or aggressive pumping technique, cracked nipples

Question 23

Mastitis - obstruction of ducts

Answer 23

Restrictive clothing, constricting bra, underwire bra

Question 24

Mastitis - feeding changes

Answer 24

Attempted weaning, missed feed, prolonged sleep (through the night), favorite side of nipple soreness

Question 25

Mastitis - lowered defenses

Answer 25

Stress and fatigue

Question 26

Engorgement

Answer 26

Venous stasis Hard and painful d/t soreness Gradual onset, entire breast affected (bilateral) No high fever Dont miss feeding, hand express or pump to soften before feed, nurse 8-12x/day 10-15min/breast (feel soft and empty - switch side), warm compress before feed for let down, cold applications btw feedings to slow milk production (ice), well fitted nursing bra 24hr/day, cabbage leaves (decrease edema), feed more frequently (q1-1.5hr)

Question 27

Weaning

Answer 27

Sub 1 cup feed for 1 cup breast over few days to a week so breasts gradually produce less Over several weeks, sub more Slow wean prevents engorgement, allows infants to alter eating methods at own rates, provide time for psych adjust (bonding time and dependence)

Question 28

PP assessment - abd

Answer 28

Loose and flabby but responds to exercise. Uterine ligaments gradually return to prepreg state, diastasis recti abd (abd muscles separate, sx, overdistended abd, linea alba stretched, bulge, PT, resolve on own) Striae colors (red = new, silver = older) Assess for after pains: intermittent uterine contractions with uterine involution, resting prone with pillow under abd helps keep uterus contracted, Motrin 600mg po q8hr prn for cramps (not if plt <70,000, careful with preE) c/s = reeda

Question 29

PP assessment - uterus: involution

Answer 29

Decrease by 100g, spongy layer of decidua sloughed off, basal layer differentiates into 2 layers (outer sloughs off, inner begins new endometrium), placental side heals by exfoliation 1 hand on fundus other on symphysis pubis: expel clots and firm fundus

Question 30

Uterus: endometritis

Answer 30

PP uterine infection Involves lining of uterus (tender, temp 100.4+, chills, foul smelling lochia Rf: c/s, PPROM, prolonged labor, multiple vaginal exams, FSE/IUPC, instrument assisted deliveries, manual removal of placenta, chorioamnionitis Treat: broad spectrum abx until culture and sensitivity, continue until afebrile 24-48hr

Question 31

Fundal assessment

Answer 31

Position related to umbilicus (6-12hr PP) and midline Firm or boggy Involution: contracts 1 finger/day Fundus descends 1cm/day until in pelvis on 10th day (palpable until) Massage: firm = well contracted (limit bleed); boggy = spongy or soft Void = higher in abd or off to 1 side Atony = more bleeding, increase oxytocin, multiparty, multiples, LGA, red haired women FF U/-1 = firm fundus, 1 finger under umbilicus

Question 32

PP assessment - bowels

Answer 32

Sluggish: progesterone, decreased muscle tone, birth process, anesthesia of c/s Episiotomy, lacerations, hemorrhoids may delay: fear of tear, stool softeners, tucks pads for hemorrhoid itching and coolness 1st BM = day 3

Question 33

PP assessment - bladder

Answer 33

Increased capacity during pregnancy, swelling and bruising of tissues around urethra, decrease in sensitivity to fluid P, decrease sensation of bladder filling (esp with epidural), output increases bc puerperal diuresis (must rid 2000-3000mL ECF), increased r/o infection (dilated ureters and renal pelvis), monitor adequacy of elimination/distention (I+O prn) UTI s/s and treatment

Question 34

PP assessment - lochia

Answer 34

After delivery, vaginal discharge of blood, mucus, atrophied uterine cells Debris in uterus discharged via lochia: rubra = red (2-4 days), serosa = pink (4-10 days), alba = white (10-20 until cervix is closed) Uterus prepreg size by 5-6 wk PP Amount - PPH, shouldn’t saturate in less than 1 hr

Question 35

PPH

Answer 35

Uterine atony!, lacerations of genital tract (fundus firm, no clots, free flow bleed), episiotomy, retained placental fragments, vulvar, vaginal, sub peritoneal hematoma; uterine inversion (prolapse of uterus, placed back in per MD), uterine rupture (hysterectomy), problems of placental implantation, coag disorders (low plt, DIC)

Question 36

PPH s/s

Answer 36

Excessive or bright red bleed, boggy without response to massage, abn clots, increased temp, any unusual pelvic discomfort or backache, persistent bleed in presence or firm uterus, increase in fundus level, pulse increased, BP decreased, hematoma or bulge/shining skin in perineal area, decreased LOC

Question 37

PPH prevent

Answer 37

Massage, assess perineum, freq void or cath, hct levels, eat foots high in Fe (oral meds), rise slowly to minimize orthostatic hypoT if blood count low

Question 38

PPH meds

Answer 38

Oxytocin: after placenta, and early PP Methylergonovine maleate: no htn Carboprost: diarrhea Misoprostol: can follow with oral drugs

Question 39

Cervical and vaginal changes

Answer 39

Cervix: spongy, flabby, maybe bruised External os: lacerations, irregular, slowly close, shape change to lateral slit (diaphragm refitted) Vaginal may be edematous, bruised, small superficial lacerations, size decrease in rugae reappear 3-4wk, prepreg state 6wk, initial healing of episiotomy lacerations 2-3 wk, complete = 6mo

Question 40

Lacerations

Answer 40

1st degree = 1 layer, 2nd = muscle (episiotomy), 3rd = to sphincter, 4 = into rectum position to assess: sidelying with superior leg elevated

Question 41

Peri assess

Answer 41

Redness Edema/swell Ecchymosis or bruising Discharge Approximation

Question 42

Peri care

Answer 42

Ice packs (1st day then warm), topical anesthetic s, waffle cushions, surgitator, sitz bath, no enemas or suppositories for 3rd and 4th, avoid C

Question 43

Hemorrhoid care

Answer 43

Sitz bath, topical anesthetic ointment, rectal suppositories, witch hazel pad, epifoam, tucks Side lying position, avoid prolonged sit Adequate fluid intake and stool softeners

Question 44

Abd incision care closure

Answer 44

Staples: remover, open to air, REEDA, shouldn’t look angry, stern strips after Dermabond closure = glue

Question 45

Care after c/s

Answer 45

Decrease resp complications: IS, deep breathe, ambulating Rest btw care of self and infant Pain manage: Percocet, Lortab, Motrin, Tylenol Decrease gas pains: ambulating, mylicon 80mg chews (dont swallow)

Question 46

PP assessment - Homans sign

Answer 46

Assess thrombophlebitis Dorsiflex foot, assess pain when walking Assess calf for size, red, warm Pain in leg, inguinal, lower abd Edema of extremity: usually 1 sided Temp change of extremity Pain with palpation Prevent: avoid prolonged sit/stand, dont cross legs, freq breaks with car trips, SCDs, early ambulating (decrease constipation, resp dysfunction, thrombophlebitis, general well being)

Question 47

Taking in

Answer 47

1-2 days after Passive, dependent, follow suggestions, hesitate to make decisions Work through reality vs fantasized experience of childbirth Food and rest

Question 48

Taking hold

Answer 48

2-3 days Ready to resume control of body, mothering Continue to provide assurance with learned skills as new mother

Question 49

Becoming a mother

Answer 49

Learn mothering behaviors Anticipatory: begin in preg, role models, fantasize, role play, expectations Formal: birth, role guided by others in social system Informal: develop new role as it fits in her lifestyle, future parenting goals Personal: internalize role and experiences harmony of self, confidence and competence in her role as mother

Question 50

Adjustment rxn with depressed mood

Answer 50

50-80% PP blues Transient period or depression, 3-5 days to 6wk, usually resolves 10-14 days, more severe in 1st time mothers

Question 51

Adjustment rxn with depressed mood - s/s

Answer 51

Mood swings (mild depression interspersed with happy feelings), self limiting, irritable/overly sensitive, episodic tearfulness without cause, difficulty sleeping, feeling of being let down, anx

Question 52

Adjustment rxn with depressed mood - rf

Answer 52

Rapid hormone changes, fatigue, discomfort, overstim, insecure, anx; emotional let down after birth, grief to loss of fantasized vaginal birth experience if c/s

Question 53

Adjustment rxn with depressed mood - nc

Answer 53

Anticipatory guidance, validate feelings and reassurance, rest (quiet time) and good nutrition, parenting reference materials, support network and inclusion of fam, open visiting hours and rooming in

Question 54

PP major mood disorder

Answer 54

PPD 3-30%, increase with hx of depression Greatest occurrence around 4th week, can occur up to 1 year after birth No mood swings -> depression Can contemplate suicide (escape and protect baby), major depression if left untreated

Question 55

PPD - rf

Answer 55

1st preg, ambivalence, hx of previous PPD or D, low support, dissatisfaction with self or body image, adolescent, socioeconomic hardship, hx of abuse, scared of meds

Question 56

PP psychosis

Answer 56

ER 1-2 per 1000 births, usually evident w/n 1-3 mo Treatment allows improvement in 2-3 mo S: agitation, hyperactive, insomnia, confusion, difficulty remembering or [], delusions or hallucinations/illogical thinking, sluicing/infanticide

Question 57

Nc: PPD and psychosis

Answer 57

Refer to mental health professional, help parents understand lifestyle change and role demands, anticipatory guidance, dispel myths about perfect mom/baby, educate about S, foster and adjustments, assess dependence, screening tool, community resource info

Question 58

PPD: treat

Answer 58

CBT is first line Sertaline 1st Paroxetine 2nd Prozac (no breast feed)

Question 59

PP psychosis: treat

Answer 59

CBT is first line Lithium, antipsychotics, electroconvulsive therapy with psychotherapy (reset brain imbalances), possible removal of infant, assess social support

Question 60

Attachment/bonding

Answer 60

Gradual exploration of newborn: fingertips, palms (larger body surface), enfold in hand and arm (holding) En face: f2f, direct eye contact, maternal response Engrossment: absorption, interest, preoccupation, paternal response Siblings: let them help, gather supplies, tour house

Question 61

Attachment/boding - bunch of shit

Answer 61

Incorporate family foals in care plan May postpone eye prophylaxis for 1hr after delivery Provide private time for the family to become acquainted Encourage kangaroo care Encourage mother to tell birth story Encourage sibling involvement Prep parents for potential problems with adjustment Initiate and support measures to minimize fatigue Help parents identify, understand, accept feelings

Question 62

Cultural support

Answer 62

Individualize care Assess level of acculturation and assimilation to western culture Involve cultural foods and familiar customs when possible

Question 63

Rest and activity

Answer 63

Encourage freq rest: sleep when baby sleeps, encourage outside help when offered Resume activity: avoid heavy lifting, avoid freq stair climbing, avoid strenuous activity

Question 64

Sexual activity

Answer 64

Resume after episiotomy healed and lochia stopped: usually 4-6 wk Lubrication may be required Contraception Potential limiting factors: fatigue, infant demands

Question 65

Discharge criteria

Answer 65

Stable VS, appropriate involution of uterus, appropriate lochia amount w/o s of infection, knowledge of s of infection, episiotomy or lacerations well approximated, ability to perform pericare and apply meds as ordered, void and pass flatus, take fluids and food without difficulty, identify s of PPD and resources, review teaching materials and cares for self and baby, display appropriate interaction with baby, infant safety, rubella non immune or equivocal status, RhoGAM (- mom, + baby, - direct Coombs)

Question 66

PP resources

Answer 66

Home health Phone follow up: best time to call PP classes: breastfeeding, BCLS Support groups