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Postpartum is when

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Delivery to return of reproductive organs to normal non-pregnant stage, often called 4th trimester of pregnancy, 6-8 weeks following delivery

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Assessment of the postpartum: History obtained from

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Antepartal: What happen during pregnacy Intrapartal: info relevant to labor and birth experience

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Assessment of Postpartum : Physical

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Vital signs, skin, color, fundus, breast, bowel. bladder, lochia, perineum, legs, pain, urinary output, iv infusions, emotional status, energy level, nutrition, knowledge

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Assessment of Postpartum: Labs

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Pre and post natal Hematocrit and Hemogloben Urinalysis, Prenatal rubella titer, antibody screen, blood type, RH factor, Hepatitis B surface antigen, Syphilis screen

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Labs: WBC Norms

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Leukocytosis occurs during labor and immediate postpartum period, as high as 30,000/mm3 Usually for baby to grow and prevent infection

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Labs: Hematocrit

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Hematocrit low when plasma increases and dilutes the concetration of blood cells and other substances carried by the plasma, Normal limits in about 4-6 weeks

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Labs: Rubella

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Done to determine whether mother is immune to rubella, if not, rubella vaccine recommended after childbirth to prevent from acquiring rubella during subsequent pregnancies, Rubella can cause birth defects, may require CONSENT to admin

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Labs: Rh Factor

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Given Rhogam to correct, Necessary when mother is Rh- and new bor is Rh+, Rhogam should be admin within 72 hours after child birth to prevent development of maternal antibodies that would affect subsequent pregnancies

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Focused Postpartum Assessment

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Breast-Check tone, Nipple Uterus-Consistency, location, position (height), should be midline Bowels-usually slows down, should return Bladder-should be able to empty Lochia-check color and amount Episiotomy/Incision- REEDA +"L-E"-Lower extremities, signs and symptoms of DVT, check emotional and nutrition

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Breast Assessment

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Looking at nipples if everted or erect vs flat or inverted Those with flat or inverted may have difficulty breast feeding, if not breast feeding, provide info on how to suppress lactation, look for cracks on nipple, redness, blisters, fissures, with those breast feeding, teach ways to protect nipples, due to cracks can make entrance for bacteria causing Mastitis which becomes a primary source of infection

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Afterpains

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Are cramps that occur after placenta detaches, helps stop bleeding, maybe a source of discomfort for many women, more acute for multiparas (more then one pregnancy) due to repeated stretching of muscle fibers leading to loss of muscle tone,

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Treat afterpains with

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Analgesics, short term

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Involution of uterus

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The return of uterus to pre-pregnancy size and condition, helps control bleeding, descends 1cm (1 fingerbreadth) per day, document U-1 or U+1 in-relation to umbilicus, Always document

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Normal Fundus

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Should be at or near level of umbilicus and midline

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Immediately after delivery fundus is

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size of a large grapefruit and can be palpated midway between the umbilicus and symphysis pubis, within 12 hours it rises to level of umbilicus

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Why would involution be slower

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Slows normally when the uterus was distended during pregnancy with more than one fetus, a large fetus, or hydramnios (excessive amniotic fluid), multiple babies Also due to Grand multiparity (more than 5 children) Prolonged Labor: causes uterus not to contract or strink Subinvolution occurs, can cause postpartum hemorrhage, common cause is retained placenta fragment

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Complications: Risk for Deficient fluid Volume related to Uterine Atony

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Causes by Excessive blood loss, Uterus not contracting Assessment includes: Fundus, check bladder, monitor and record I and O every 4 hours, at least 250ml per void, Monitor Vital signs, BP, HR, RR, Pulse ox, Labs H & H

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Expected outcome for Risk for Deficient fluid Volume

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Fundus remain firm, lochia moderate and no evidence of hemorrhage throughout hospital stay

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Nursing Actions to encourage Uterine Contractility

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Uterine Massage Breast feeding stimulates release of oxytocin, receptors found on uterus Patient Education: Tell why done and why important Empty Bladder Express uterine clots Admin Meds to prevent hemorrhage: Oxytocin (patocin) IV/IM, Methergine: Has vasoconstrictive effects, causes massive arterial vasoconstriction

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Assessing Lochia: Color: Rubra

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Red, First 1-3 days

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Assessing Lochia: Color: Serosa

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Pinkish-red/ brown tinged, Day 4-10

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Assessing Lochia: Color: Alba

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White/cream, 11-end of 6 weeks

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Assessing Lochia: Amount: Scant

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spotting, <1 inch stain

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Assessing Lochia: Amount: Light

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1-4 inch stain

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Assessing Lochia: Amount: Moderate

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4-6 inch stain

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Assessing Lochia: Amount: Heavy

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Saturated pad within hour

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Assessing Lochia: Amount: Excessive

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Saturated pad within 15 minutes

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Assessing Lochia: Odor

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Should not be foul smelling

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Assessing Lochia: Always ask

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Always ask when pad last changed

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Postpartum Hemorrhage

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Is blood loss that exceeds 500mL after a vaginal birth or 1000mL after a cesarean birth, decrease hematocrit of 10% or more Excessive bleeding that makes client symptomatic and or results in signs or hypovolemia leading cause of maternal morbidity and mortality worldwide

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Why might bleeding occur: The 4 T's

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Tone: Diminished; atony or absent (70%) Tissue: retained placenta, small fragment prevent site from closing Trauma: laceration, maybe from birth canal, laceration, or hematona Thrombin: Coagulopathy (<1%) clotting issue

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Early postpartum Hemorrhage

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Most common during first hour after delivery Major 2 causes are uterine atony and trauma to genital tract may also be due to placenta accreta which is an abnormally adherent placenta (won't detach away from uterus) causing excessive bleeding.

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Predisposing factors of Postpartum Hemorrhage

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Over distention of the uterus (multifetal, large infant, hydraminos) Multiparty greater than or equal to 5 use of tocolytic drugs (they relax the uterus) Precipitate labor or delivery ,3hours prolonged labot 12-18 hours use of forceps or vacuum extractor cesarean birth manual removal of placenta previous postpartum hemorrhage general anesthesia placenta previa/accreta mag sulfa admin (relaxes smooth muscles) clotting disorders previous uterine surgery

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Clinical signs of uterine atony (uterus not contracting)

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A uterus difficult to locate, soft or boggy uterus, uterus that becomes firm as it is massaged but loses tone when massage is stopped, uterine fundus located above the expected level,excessive lochia (esp is bright red), Excessive clots expelled, if constant trickle of lochia (may have laceration contact HCP)

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Nursing care of uterine atony: Physical Aspect

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Stop the flow (bleeding), massage the fundus (priority), If it does not stay firm, should empty bladder, reassess, if still can't void must be cath. Assess: fundus, lochia, bladder, vital signs, skin, temp/color Weight peripads for a more accurate estimate of blood loss: 1gram=1mL

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Nursing Care fro Uterine Atony: Pharmacological aspect: Oxytocin

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Rapid infusion of dilute oxytocin (pitocin), first drug of choice due to less likely to cause hypertension

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Nursing Care fro Uterine Atony: Pharmacological aspect: Methergine

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Second Line drug, increase vasoarterial constriction, need to assess BP before given, if devated >140/90, hold and notify HCP, PO methergine has fast onset and works very quickly

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Nursing Care fro Uterine Atony: Pharmacological aspect: Hemabate (or prostin/15M)

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stimulate contractility of uterus, IM/Direct injection into uterus during C-section, Side effects are caution for women with asthma due to it metabolizes in lungs, N/V/D, headache, fever, chills, admin antimetics and antidiureheal and antipyretics with it

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Nursing Care fro Uterine Atony: Pharmacological aspect: Misoprostol (cytotec)

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600mcg, sublingual or rectally, controls hemorrhage

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Nursing Care fro Uterine Atony: Pharmacological aspect

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If meds do not stop bleeding may need to go to OR or have historectomy done

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Birth canal Trauma: Lacerations

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Occur at perineum, Vagina, cervix, and the area around urethral meatus are most common areas, always suspect laceration if there is excessive uterine bleeding and uterus is firmly contracted, bleeding often Bright Red, usually occur during second stage of labor when fetal head descends rapidly or when assistive devices such as vacuum extractor or forceps used to assist with deliver.

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Birth Canal Trauma: Hematomas

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Occur when bleeding into loose connective tissue occurs while overlying tissue remains intact Develop as a result of blood vessel injurt in spontaneous deliveries/vacuum/ forceps Produce deep, severe, unrelieved pain and feelings of pressure Suspect hematoma formation if: woman c/o perineal/vaginal pain and demonstrates systemic signs of concealed blood loss (tachycardia, Decrease BP, Pallor) Also when fundus is firm, lochia normal but has complain of not feeling well, dizzy, cool to touch

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What do you see with Hematomas

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Discolored bulging mass that is sensitive to touch, if ,5cm insize pack with ice, it will absorb naturally Large hematomas may require incision evacuation of the clots and ligated bleeding vessel

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Complication: Late Postpartum hemorrhage

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Typically occurs without warning between 6days-6weeks postpartum caused by subinvolution and retained placental fragments, usually occurs at home, teach hoe to assess fundus and the normal duration of Lochia, Instruct to notify HCP if bleeding persists

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Subinvolution of the Uterus

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A slower-than-expected return of the uterus to its nonpregnant size after child birth Causes: retained placental fragment and pelvic infection Signs and Symptoms: prolonged lochia or discharge, irregular or excessive vaginal bleeding, and sometimes profuse hemorrhage, pelvic pain, pelvic heaviness, backache, fatigue, malaise, Lochia rubra to serosa to rubra pattern

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Management of Subinvolution

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Methergine: .02mg Po for 24 to 48 hours every 4-6 hours Creates a long, sustained contraction of the uterus Correct cause by: evacuation of retained clots or placental fragments if present,Treat infection if present with antibiotics, nurses must teach the mother and family how to recognize its occurance and seek care

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Nursing interventions to treat Excessive Bleeding

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Initiate fundal massge, Notify MD/CNM immediately, Anticipate obtaining labs (H&H, T&C for blood, platelets, clotting studies) start and maintain IV with a large gauge angiocath (18G) give fluids or blood Drugs: Patocin, Methergine, Hemabata Keep woman on bedrest (to aid venous return and maintain cardiac output)

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Post Hemorrhage Care

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After hemorrhage is controlled, continue to assess the woman frequently-watch for resumption of bleeding Allow rest periods and organize care to help her conserve energy Orthostatic hypotension may occur, assess for dizziness and low BP, dangling legs and rising slowly Encourage iron-rich diet, continue prenatal vitamins for at least 6 weeks to build strength and blood counts back up

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Potential Problem with Postpartum: Potential for Impaired Urinary Elimination or urinary Retention

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related to pelvic and or effects of anesthesia Expected outcome is Patient will void withing 6-8 hours following delivery

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Potential Problem with Postpartum: Potential for Impaired Urinary Elimination or urinary Retention: Nursing Actions

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Physical care: assess bladder for location and distention, measure I and O for first 2-3 voids after birth (or removal of foley) at least 250mL each void, Bladder distention produces bulge above symphysis pubis with displacement of uterus, Remind to void

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Signs of a distended bladder

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Fundus above basline level, Fundus displaced from midline, excessive lochia due to uterus not contracting, Bladder discomfort, bulge of bladder above symphysis pubis, frequent voiding of >150ml each

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Nursing Actions for not being able to void

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Ice to perineum: done first 12-24 hours to reduce swelling, assist to bathroom or provide bed pan, warm water over perineum (peribottle), listen to running water, place hands in water, warm shower, sitz bath, catherterize if necessary (last resort)

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Complication that may occur Postpartum: risk for constipation (or risk for dysfunctional GI motlity)

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related to perineal trauma (epis, lac, hemorroids) fear of pain Expected outcome: patient will have a BM within 48-72 hours of delivery

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Complication that may occur Postpartum: risk for constipation (or risk for dysfunctional GI motlity): Nursing Actions

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Assess perineal/ perianal care Diet: increase fiber and fluids Exercise: Ambulate Avoid excessive use of narcotics Topical anesthetics, oral analgesics Stool softeners (colace, lacitives, senekot, ducolax, milk of mag) Sitz bath and perineal care

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Complications that may occur Postpartum: Risk for impaired comfort

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related to tissue trauma during delivery, episiotomy, afterpains, breat tenderness, gas Expected outcome: Patient will rate pain as less than or equal to 3 by discharge

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Complications that may occur Postpartum: Risk for impaired comfort: Nursing Actions

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REEDA, analgesics, ice packs for first 12-24 hours, sitz bath 2-3 times a day, after 12-24 hours, warm shower, ambulate, rocking chair

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Perineal Lacerations: First Degree

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Superficial vaginal mucosa or perineal skin

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Perineal Lacerations: Second degree

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Vaginal mucosa, perineal skin, and muscles of the perineam (episiotomy)

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Perineal Lacerations: Third degree

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Vaginal mucosa, perineal skin and muscle of perineum and involves anal sphincter

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Perineal Lacerations: Fourth degree

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Extends thru anal sphincter and into rectal mucosa

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Fir 3rd and 4th degree lacerations you to to encourage

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Higher fiber and fluids to have soft stools

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Periurethral Tears

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Tears in urethra more likely to happen with foreign baby in face up position Can cause swelling around urethra which can lead to difficulty voiding.

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Normal vital signs in 4 hours after delivery

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T: 100.4 degrees P: 60 R:18 BP: 110/58

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Normal vital signs in 4 hours after delivery Why

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After delivery slight temp elevation up to 100.4 degrees is normal due to dehydration, fatigue and leukocytosis Increase temp more than 24 hours or above 100.4 need to be further assessed and reported Increase WBC 14000-16000 average or high 30000 after delivery is normal due to body stress response Bradycardia is normal due to large amount of blood being returned to maternal central circulation after placenta delivers Respiratory rate should not change usually 12-20 breaths average Low BP could be from hypovolemia check pulse if decrease BP, increase pulse which is hypovolemia High BP could be due to pain or excitement or pre-eclampsia ( a complication that may occur in 3rd trimester but potential risk of postpartum period

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Potential complication for Postpartum: Risk for Infection

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Related to child birth trauma to tissues, episiotomy, incisions and altered primary defenses Expected outcomes: Client will show no evidence of infection throughout recovery period

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Potential complication for Postpartum: Risk for Infection: Nursing Actions

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Assess Vital signs every 4 hours, Inspect perineum or incision every 8 hours, assess lochia (odor and appearance), promote good hygiene, peri care, hand washing, Sitz bath to promote healing

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Infection: Client with metritis should be placed on

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Fowler's position to promote drainage of lochia

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Potential sites for postpartum Infection

answer

Heart, Lungs, kidneys Peritoneum Femoral and ovarin veins Vulva, Vagina and perineum Endometrium Cervix

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General Symptoms of Postpartum Infection

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Fever >100.4 degrees F (38 degrees C) after the first 24 hours and lasting 2 or moresuccessive days with 2 consecutive readings chills, flu-like symptoms, elevated WBCs (>30000/mm) Uterine subinvolution, other symptoms vary depending on site of infection

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Nursing Actions for Postpartum Infection

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Involve admin of antibiotics and relieving pain

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What to look for in assessment for infection

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V/S: Elevations Labs: WBC , Cultures Lochia: Foul Smell Breast: redness, warmth, nipple cracks and fissures, engorgement S/S: pallor, fatigue, malaise, decrease appetite, pain, redness, edema, heat, drainage Urine: Cloudy, color, odor, sediment

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Physical and Nutritional Nursing Actions for Risk of Infection

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Standard precautions: Clean environment, no bare feet, handwashing Aseptic technique for invasive proceudres Hygiene: wipe front to back, peri care, sitz bath Nurtition: protein, Vit C, Iron Screen visitors and keep those with infection away

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What do you do for the Woman who develops Mastitis

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Staph A causes Breast Infections Can occur due to cracks in nipple or blocked milkduct should promote drainage by encourage frequent breast feeding to avoid engorgment If have mastitis need to be on antibiotics can continue to breast feed, cant pass on to baby

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Thromboembolic Disorders: Superficial Venous Thrombosis

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Generally involves the saphenous venous system and confined to lower legs

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Thromboembolic Disorders: DVT

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Can involve veins from the foot to the iliofemoral region predisposes to PE

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Thromboembolic Disorders: PE

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Fatal complication that occurs when pulmonary artery is obstructed by a blood clot, Swept into circulation by a vein or by amniotic fluid

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Common causes of thromboembolic disorders

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Venous statsis in pelvis and lower extremities, normally present in pregnancy. Compression of large vessels due to inactivity, standing long time Hypercoagulation normally present in pregancy, increase risk for thrombus formation Blood vessel injury my occur during cesarean birth and could trigger a pelvic vein thrombosis

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Nursing Diagnosis: Risk for peripheral Neurovascular Dysfunction (DVT)

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Related to immobility and inflammation Expected outcomes: patient will have no signs or symptoms of DVT

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Nursing Diagnosis: Risk for peripheral Neurovascular Dysfunction (DVT): Nursing Actions

answer

Assess lower extermities: redness, swelling, head, pain, pedal edema Prevention: ambulat, ASAP. TEDS, SCDS, ROM, avoid knee flexion Treatment: Bedrest with leg elevated, anticoagulants, analgesics, antibiotics

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Why should Homan's Sign no longer be done?

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Due to evidence based practice, found that women will complain of calf pain, but not having to do with clots just position of leg and holding of legs, also dorsiflex may dislodge the clot

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Pulmonary embolism (PE)

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Patho: Blood cot or amniotic fluid debris released into blood stream and obstructs pulmonary vessels, serious complication of DVT, leading cause of maternal death Signs and symptoms: Tachycardia, tachypnea, dyspnea, chest pain, coughing, low grade fever, low O2 sat, hemoplysis, abdominal pain

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Pulmonary embolism Nursing Actions

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Monitor for signs of PE when caring for a woman with DVT and Report and Prepare for ICU transfer

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Psychosocial Adaptations: Bonding

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Rapid Initial attraction felt by parents soon after child birth

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Psychosocial Adaptations: Attachment

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Process by which an enduring bond between parent and child id developed through pleasurable interaction

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Psychosocial Adaptations: Maternal Touch

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Fingertips to palms to entire hand to enfold the infant and her baby close to her body

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Psychosocial Adaptations: Enface Position

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Mother's face and teh infant's face are in the same vertical plane, when the infant is awake mother and baby engage in prolonged gazing

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Psychosocial Adaptations: Verbal Behaviors

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Transition from calling baby "it" to "him" or "her" to baby's name

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Puerperal Phases

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By Reva Rubin (1960s) Restorative phases that the mother replenish the energy lost during labor and attain comfort in the role of mother 3 phases-taking in, taking hold, letting go

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Puerperal Phases: Taking-in Phase

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Mother focused on self and meeting own basic needs of laboring birth over and over again as she talks to everyone, mother is passive and dependent, major task: integrate her birth experience into reality, last a day or less may be prolonged with cesarean birth

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Puerperal Phases: Taking-Hold Phase

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Mother becomes more independent, exhibits concern about managing her own body function and assumes responsibility for her own care, when she feels comfortable and in control on her own body, she shifts her attention to her infant, extends over several days or weeks, best time to teach

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Puerperal Phases:: Letting-Go Phase

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Time of relinquishment for the mother and often the father, couple give up their previous role as a childless couple and acknowledge a loss of that lifestyle, mast relinquish fantasies and accept reality, often provokes subtle feelings of grief encourage open communication, occur 7 days after delivery, focus on moving forward as a family unit

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Potential Psychosocial nursing Diagnosis: Risk for interrupted family processes

answer

related to pain, fatigue, knowledge, support, expectations expected outcome: parents will demonstrate positive bonding behaviors with baby prior to discharge

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Potential Psychosocial nursing Diagnosis: Risk for interrupted family processes: Nursing Actions

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Encourage parental contact during infant quiet/alert status, rooming-in vs. nursery, model appropriate parenting behaviors, teach newborn care, encourage rest and good nutrition, identify support systens

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Weight Loss in Postpartum

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10-13 lbs are lost right after birth due to loss of placenta and amniotic fluid, blood additional 5-8lbs due to diaresis and loss of 2-3 lbs from involution and lochia first week normal weight gain of 25-30lbs from pregancy reassure that this is normal usually takes 6-12 months to lose weight gained

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Postpartum (baby) blues

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Transient, mild condition; peaks at about 5 days postpartum and subsides within 2 weeks, cause unknown, physical factor: fatigue,

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Postpartum (baby) blues: Psychological factors

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Mother may be overwhelmed by new role and responsibilities, feel a loss at separation of baby and self, feel a lack of attention and support that existed in pregnancy

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Postpartum Depression (PPD)

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A period of depression that begins after childbirth, and last at least 2 weeks, associated with a personal or family history of depression, poor social support, problems during pregnancy

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Postpartum Depression (PPD): Signs and Symptoms

answer

anxiety, fatigue, sleeplessness, difficulty concentrating making decisions, appetite change, crying, sadness, lack of energy, suicidal thoughts, requires meds, psychotherapy, support

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PPD Impact on Family

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Creates strain on each member's usual methods of coping and often causes difficulties in relationships

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Postpartum Psychosis (rare)

answer

1-2 out of 1000 women mean time onset 2-3 weeks after birth 30-50% recurrence rate history of bipolar disorder is an important risk factor Assess: feeling of guild, worthlessness, sleep and appetite disturbances, inordinate concern with baby's health, delusions of dead baby, possessed, or defective are common, Hallucinations present in severe cases

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Management of Postpartum Psychosis

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Beyond scope of maternity nurses, Need to be sent to a psychiatric emergency, hospitalization, Meds are usued as appropriate, antipsychotics, antidepressants, exercise caution in use of pharmacologic agents if woman is breast feeding

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Family Planning

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Introduced topic as part of discharge planning, nurse should be able to help by providing up-to-date, accurate info about contraceptives and helping clients find methods that best meet their needs

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