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What is involution?
Decrease in size of uterus after delivery of baby & placenta
The most drastic postpartum changes are in the ________ system
The uterus does what to return to pre pregnant size and prevent postpartum hemorrhage?
How long does it take for the uterus to return to its pre-pregnancy size after delivery?
Approximately 6 weeks
Immediately after delivery, the fundus rapidly contracts to facilitate compression of intra myometrial blood vessels. Where does the fundus measure immediately after delivery?
Midline, midway between umbilicus and symphysis pubis
What is the location of the fundus at 12 hours post delivery?
level of the umbilicus
What is the location of the fundus at 1 week post delivery?
Level of the symphysis pubis
What is lochia? what does it contain?
- Discharge from the uterus through the vagina after birth.
- Contains blood, tissue, mucus
Describe the appearance and occurrence of lochia rubra
Bright red. Occurs first few days after delivery
Describe the appearance and occurrence of lochia serosa
- Occurs until the 7th day after delivery
- As placental site heals, discharge becomes pinkish to brownish
Describe the appearance and occurrence of lochia alba
- After the 7th day, Continues for 10 days to 2 weeks after lochia serosa
- Yellowish to whitish
Why would retained placental tissue cause postpartum hemorrhage?
- Interferes with complete involution
- Muscles cannot tighten around all of the blood vessels in the uterine wall
Describe the appearance of a well healing episiotomy and how long it takes to completely heal
- Approximated edges
- No erythema, edema, discharge
- Takes 2-3 weeks to completely heal
When does normal menstrual cycle return after delivery? nursing mothers vs bottle feeding mothers
- By 6th week to 6 months
- Later in nursing mothers
- Earlier in bottle feeding mothers
Can you still get pregnant before your menstrual cycle returns?
What is meant by lactation?
function of secreting milk or period during which milk is secreted by the breasts
Describe and define colostrum
- First secretion
- Pale yellow with a thin, watery consistency
- Contains large amounts of protein, calories, lymphocytes and antibodies
What happens to levels of estrogen, progesterone, and prolactin after delivery?
- Estrogen and progesterone levels drop rapidly
- Prolactin increases to stimulate milk production
What is the function of oxytocin postpartum?
- Stimulates mammary ducts to contract: Let down reflex
- Also causes uterine involution, therefore breast feeding helps stimulate uterine contraction which can be referred to as "afterpains", especially during first few days of nursing
How does breastfeeding promote involution of the uterus?
Nipple stimulation promotes uterine contractions
What is engorgement and when does it occur?
- Uncomfortable fullness of breasts that occurs during lactation when milk is first coming in.
- Occurs about 3rd postpartum day (3-5 days) and lasts about 48 hours
- Breast feeding moms are relieved with feeding
How does the body decrease blood volume to nonpregnant levels?
Diuresis (increased formation & secretion of urine) and diaphoresis (secretion of sweat), blood loss during delivery also helps rid body of extra volume and decrease cardiac output
Why might a postpartum pt experience urinary retention?
Trauma, increased bladder capacity, effects of conduction anesthesia, all decrease urge to void; Pelvic soreness caused by forceps, vaginal lacerations, or episiotomy reduce/alter voiding reflex
Why might a postpartum pt experience constipation?
- Reduced gastric motility
- May be hungry after delivery, but peristalsis may mot be as active
- Tenderness of the abdomen or perineum may impede straining to have a BM
postpartum pts need assessed frequently for signs of infection and other complications. Why?
- OB pts are discharged quickly
- Nurses need to observe early indications of problems
What is BUBBLE-HE
- H-Homan's Sign
- E-Emotional State
What should the nurse assess for when checking the breasts?
Heat, engorgement, erythema, nipple cracks, fissures, soreness
How should pt be positioned for breast assessment
Lying down with bra off
how does the nurse assess the fundus of the uterus?
Palpate the abdomen at or below the umbilicus, feeling for a firm top (like a grapefruit)
how should the fundus feel?
how does the nurse describe the location of the fundus?
- In relation to umbilicus
- At umbilicus or fingerbreadths above or below (2/U or U/2)
What assessment of the fundus could indicate potential complications?
Soft fundus (boggy) = potential hemorrhage
What should the nurse do to help the uterus contract and remain contracted?
Massage the fundus
How is uterine inversion and hemorrhage prevented?
Never palpate fundus without supporting the lower uterine segment. Doing so may result in uterine inversion and hemorrhage
What assessment of the bladder should the nurse make?
signs of UTI or urinary retention
What assessment of the bowels should the nurse make? How can constipation be prevented?
- Bowel sounds
- Encourage fluid intake and activity with rest periods to help prevent constipation
List 3 assessment of vaginal discharge (lochia)
- 1. Odor
- 2. Color
- 3. Amount - estimated by number of pads saturated per hour
List 4 descriptions of lochia amounts
scant, light, moderate, heaby
List 2 indications of potential complications regarding lochia
- Fetid odor (infection)
- heavy discharge or steady trickle (hemorrhage)
- **Always check under buttocks for blood***
How should nurse assess episiotomy, hemorrhoids, and/or perineal lacerations?
Place on side, flex upper leg, lift buttocks to inspect
What would indicate presence of perineal hematoma?
would cause edema, severe pain, and discoloration
Why is checking Homan's sign important?
Pt is high risk for developing thrombophlebitis due to hormone changes and decreased blood volume.
What should you do if Homan's sign is positive?
Call MD immediately
List 4 assessments to make regarding the postpartum emotional status
- Interactions w/family
- Interations w/infant
- Level of independence
- Amount of sleep and rest she is getting
- emotional stability (crying, mood swings, irritability)
What additional assessment(s) will you make if pt had cesarean birth?
- Assess wound for redness, drainage, and approximation
- Temperature, incisional pain
- Bowel sounds
- Lung sounds, turn, cough and deep breathe
- incentive spirometry
- Appropriate support for breast feeding (keeping pressure off of incision)
- **can have surgical complications**
INFO: Some mothers assume that infants know how to breastfeed
Correct positioning ensures areolar tissue is completely in the infant's mouth
Infant will suck, but without proper latch will cause mother to become sore, and baby to not get enough milk
What type of bra should the nursing mother wear?
Supportive and comfortable
When does engorgement usually occur?
Around the 3rd day postpartum when milk comes in
What should the mother be taught to do to relieve the discomfort of engorgement?
Manually expressing milk, breastfeeding the baby and applying warm, moist packs to the breast (if breastfeeding) or ice packs, wear a firm compressing bra and take analgesics (if bottle feeding)
how can pt keep nipples soft & supple?
- allowing to dry with mild residue on them
- use unscented lanolin or nipple cream
- Wash with water & let air dry
- Properly position baby to nurse to prevent soreness "Baby to belly, nose to nipple"
What is let down and when does it occur?
- Tingling or prickling sensation in the breasts when feeding time approaches
- Response to oxytocin release
How should baby's mouth grasp nipple so milk will be released?
- Mouth should grasp nipple and areola
- mouth applies pressure to the mammary glands in the areola to stimulate release of milk
When is manual pumping of the breasts to obtain breast milk recommended?
When baby is unable to suck well (cleft lip/palate, NICU, preemie, Working mother)
how does nursing benefit baby?
- Provides anti-infective properties from the mother
- Complete nutrition
- Lowers risk of SIDS
- Promotes good jaw alignment and tooth development
- reduces allergies
- Reduced risk of DM I and II, heart disease, and inflammatory bowel disorders later in life
- Decreases risk of obesity
- Increases intelligence
- helps with bonding
- saves $1500/year
how does nursing benefit mother?
- Aids in uterine involution
- reduces risk of breast and ovarian cancer
- promotes nurturing and relaxation
Describe parent/infant bonding
- Begins immediately after birth
- En face position-holing infant close, looking into the eyes
- Normal to check to ensure all finger/toes are in place
- May talk in high pitched tones
- Compare infant to family resemblance
Nursing support for bonding
- Allow parents time immediately after birth to bond
- Shield infant from bright lights to help it open its eyes
- weighing, measuring, eye gtts can wait 30 minutes to an hour
- Support during initial breastfeeding within first hour after birth if possible
- If infant has a defect, focus on the positives
Difficulties with bonding
- Disinterest or refusal to care for baby
- Exhaustion from L&D
- Support mother rather than casting judgment
- May be overwhelmed
- Discuss differences between expectations & reality
- MD should be made aware in case referral/follow up is needed
- May cause difficulty with bonding
- High tech care
- Encourage parents to hold baby and bond
- may be fearful of touching, or hurting baby/damaging equipment
- Support parents, explain equipment/procedures to allay fears
Adapting to birth: Phase I:Taking In
- Focus is on recovering from L&D
- Foods, fluids, rest
- Passive, allowing others to care for her
- Processes what has happened, important that she talk about her L&D experience
- may tell story over and over
- May question regarding details she remembers unclearly
- Normal part of transition from expectant mother to mother
- lasts 1-3 days
Adapting to birth: Phase II: Taking hold
- Independent in her own care and care of infant
- Ready to learn about how to care for infant and expected behavior
- Father may have similar feelings and behaviors
- lasts 10 days
Adapting to Birth:Phase III: Letting Go
- Giving up some of couples past life-style choices because infant must come first
- Let go of preconceived ideas about the birth experience or infant's appearance or gender
- Reality must be accepted and expectations of what might have been released
- Parents let go of their role as expectant parents and embrace their role as real parents with a real baby
- normal part of recovery
- Mother may be more emotional than usual, cries easily
- R/T changes in hormone levels after birth
- may also have feeling of anxiety, restlessness, sadness and fatigue
- usually begins about 3 days after delivery
- usually gone about 10 days after delivery
- support the mother
- Assist with infant care as needed especially when the mother seems overwhelmed or needs rest
- not a normal part of postpartum recovery
- lasts longer and is more severe than postpartum blues
- mild, moderate or severe
- care for the infant, but may not feel love
- conflicting emotions-guilt, irritability, loss of herself
- last longer than a few weeks after birth
Moderate postpartum depression
difficulty sleeping, cry for no reason, experience decreased ability to focus
severe postpartum depression
- may be out of control, crying or angry
- may have negative feelings toward infant and be ashamed of feelings
- may be extremely difficult for her to verbalize feelings
- partner, friends, family and health care workers must be alert to these symptoms and ensure that she is evaluated by a professional
Post partum psychosis
- May be delusional and have thoughts of harming herself or her infant
- sleeplessness, crying, incoherent speech, confusion, disorientation, delusions, or hallucinations
- RARE, BUT PSYCHIATRIC EMERGENCY
- Treated with psychotherapy and psychotropic medications
- imperative that partners, friends, family and health care workers recognize postpartum psychosis as far more severe than blues or depression
- Mother should be taken to a MD or psychiatric facility
- 1998 report showed that 5% committed suicide and 4% committed infanticide
- Difficult for a new mother to verbalize feelings of depression, anxiety, fatigue or anger to friends/family
- May keep feelings inside and not seek help
- Nurses need to be acutely aware of unspoken needs of a new mother and ask questions that will help her verbalize her feelings
- Often focus is on infant
- If infant does not do well, mother may feel at fault
- always ask mother how she is doing and encourage her to verbalize her own fear and frustrations
Postpartum complications: PN must frequently assess for S/S of:
- Perineal hematoma
- puerperal Infections (may present as endometritis (most common), myometritis, parametritis, pelvic abscess, salpingitis, septic pelvic thrombophlebitis or septicemia, and also includes infections of the urinary tract, episiotomy, surgical wounds, lacerations or breast)
- Postpartum hemorrhage (mild to life threatening)
Nursing care for pt w/vaginal or perineal laceration (tearing of birth canal during delivery or trauma to perineal area):
- Administer analgesics as ordered
- Observe lacerations for increased swelling or drainage
- Apply heat or cold as ordered
- Assess for constipation (stool softeners as ordered, encourage fluids)
Postpartum care of pt w/lacerations:
NEVER administer enemas or suppositories to a pt who has lacerations from the anus to the vagina
Are c/o "after pains" normal one day postpartum?
What is a perineal hematoma?
- Collection of blood in the perineal tissue
- Purplish mass may be visible
What causes a perineal hematoma?
- Forceps delivery
- Excessive pressure from the fetal head during labor
What may pt complain of with a perineal hematoma?
pain or fullness in the vagina
What kind of procedure may be needed to treat a perineal hematoma?
Care of perineal hematoma
- Assess vaginal packing for drainage and position
- Administer pain meds and ATB as prescribed
- Assess I&O
- Provide catheter care
Peurperal infections: What are they?
Infection that occurs anywhere in the genital tract (vagina, cervix, or uterus)
Peurperal infections: What causes them?
Peurperal infections:Why are they easily infected?
Bacteria from BM, lots of blood, drainage, warm and moist environment
Peurperal infections: S/S
- Elevated temp >24 hours after delivery
- Foul smelling lochia (report immediately)
- Enlarged and tender uterus
- Rapid pulse and respirations
Peurperal infections: What position should pt be in and why
Bedrest and fowler's position to promote pelvic drainage
Peurperal infections: Aseptic or not
Peurperal infections: Assess lochia for
amount, color, odor
Peurperal infections: Administer:
ATB and analgesics as ordered
Peurperal infections: PN should promote what type of exercise and why
Leg exercises to promote circulation
Thrombophlebitis: Caused by
- Venous Stasis
- Excess fibrinogen
- Hormonal changes that increase clotting tendencies
- Positive Homan's Sign
- Redness, pain, swelling of leg
- Fever and chills (possibly)
- Anticoagulants to prevent further clot formation
- Measure calf circumference to assess edema
- Keep leg elevated
- Maintain bedrest as ordered
- Assess PT, PTT, INR results
- Observe for hemorrhage as side effect of meds
- massage leg or allow the pt to massage leg, even though it may feel good
- Teach pt that massage may cause clot to move
Postpartum complication-PE:Occur as result of
- Severe Hemorrhage
- Chest pain
- Extremely anxious
- Lack of uterine muscle tone
- retention of pieces of the placenta
- genital infection
- multiple births
Postpartum complication-Hemorrhage: May have blood loss of _______CC or more. S/S of hypovolemic shock
Postpartum complication-Hemorrhage: MD should be notified of
Increased or excessive vaginal bleeding
Postpartum complication-Hemorrhage: What can be done w/fundus
massaged to stimulate uterine contractions and increase uterine tone (involution)
Postpartum complication-Hemorrhage: What may need to be done
- D&C (dilation & curettage)
- Massage fundus
- Administer O2
- Prepare pt for the D&C
- Complete pre-op checklist for D&C
Postpartum complication-Hemorrhage: How do you assess amount of bleeding?
Count number of pads used in a given length of time
Postpartum complication-Rh incompatibility:Meaning & Treatment
- Mother Rh - and father Rh+
- Baby could be Rh+
- Administer RhoGAM (desensitizing drug given to prevent mother's antibodies from destroying the baby's RBCs)
Postpartum complication-Rh incompatibility:When is RhoGAM given
28 Weeks & repeated 72 hours after delivery
What should pt be taught about color of lochia and how long to expect it
- Teach about 3 types (rubra,serosa,alba)
- lasts 3-4 weeks after delivery
How is lochia different when a pt has had a c-section
Less lochia as uterus was suctioned during the cesarean delivery
What characteristics of lochia should the mother report to the MD
Bad odor, bright in color, large clots
How should the mother cleanse the perineal area
- FRONT TO BACK
- Using spray bottle (peri-bottle) each time she eliminates
- May take sitz baths or use TUCKS pads to relieve discomfort
- Pt should avoid wiping with toilet tissue
When should the mother change her peri-pad
After every void or when it becomes soiled
How long will it take the episiotomy to heal
2-3 weeks (around the same time lochia stops)
When can mother resume using tampons or douching
Once seen by MD and given permission to do so
When can mother shower
Anytime as long as PN is checking on her frequently and close by
When can sexual activity resume
- After pt has had her first visit to MD and has been advised that it is permissible (4-6 weeks)
- *if pt asks be matter of fact and instruct her to check with MD at her follow up visit
- Teach parents what to expect
- Listen to concerns
- Support parent choices (bottle/breast, circumcision)
Emotional Support of new parents
- Include father/partner in teaching and demonstrations of infant care
- Do not be overly critical of new parents
- Allow parents to discuss concerns in a supportive environment
- Cultural differences need to be discussed prior to discharge of mom and baby
Emotional support: A baby in the NICU can be _______
Emotional Support: If mom wants to breastfeed and can't d/t infant illness
encourage and assist her to pump her breasts so baby can be fed her milk
Praise new parents:
- As they learn how to care for baby
- Encourage contact with the baby
Emotional Support: Single Parents: How can PN help?
- Ask about support system (who helps, gives advice, can she depend on)
- Ask about her health (is she eating and sleeping enough)
- Ask her how she is feeling & really listen to the answer
- Give her opportunities to talk about her feelings
- Praise her for all the things she is doing and how hard she is working
- Point out how well the baby responds to her and that the baby is attached to her
- Help her verbalize fears & frustrations
- Allow her to talk without being judgmental