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What are the physiological changes that take place during postpartum with regards to the reproductive system?
Involution of uterus; descends 1-2 cm each day. Cannot not be palpated after the 9th postpartum day.
Normal estrogen levels return by 10 weeks.
Ovulation occurs in 10-12 weeks for non-lactating women; 12-16 weeks for lactating women.
Lochia occurs in 3 stages.
What are the 3 stages of Lochia
Lochia rubra. Bright red and lasts for the first three days
Lochia serosa. Pinkish and watery. Present from day 3 to day 10
Lochia alba. Whitish tan color. Appears after the 10th day and can last as long as six weeks
How do you assess lochia amount?
What are the physiological changes that happen in the breasts during postpartum?
- Colostrum is secreted immediately after delivery
- Milk production begins 3-5 days after delivery
- Physiological Changes
What are the physiological changes that happen in the cardiovascular system during the postpartum period?
- Blood volume decreases after day 3, as the excess fluid accumulated in pregnancy is eliminated
- Diaphoresis eliminates much of the fluid via the skin.
- Clotting factors remain elevated (increasing risk of DVT) but returns to normal by the third week.
What are the physiological changes that happen in the urinary system during the postpartum period?
Diuresis begins within 12 hours of birth
- Helps eliminate excess fluid. Output may be
- 3,000 mL/day during the first week
Bladder tone is restored by the end of the first week
- Edema of the perineum may cause difficult voiding and urinary retention during the
- first 24 hours. An epidural also may cause retention.
What are the physiological changes that happen in the gastrointestinal system during the postpartum period?
Normal bowel function returns by the end of the first week
Stool softeners should be used if episiotomy present
In the immediate postpartum period, patient may be very hungry and thirsty
How will vital signs change during the postpartum period?
- Vital signs do not change much under normal
Temperature may rise slightly during first 24 hours due to dehydration during labor; hormone changes Encourage fluids to rehydrate
Pulse decreases to pre-pregnancy rate by 8-10 weeks
Respiration rate decreases to normal prebirth range by 6-8 weeks
Blood pressure usually not altered; orthostatic hypotension may occur during first 48 hours
Nonpathological leukocytosis often occurs during labor and in the immediate postpartum period
WBC values typically return to normal levels by the end of the first postpartum week
Leukocytosis combined with the normal increase in erythrocyte sedimentation rate (ESR) may obscure the diagnosis of acute infection at this time
What are the nursing interventions during the postpartum period?
- Provide warm blankets for “postpartum chill”
- during the first 2 hours. Normal response
- Replace fluids and food to replace fluid loss
- and boost energy
- Perform physical assessment: B/P, pulse,
- temperature, lochia, fundal height/firmness, bladder, perineal healing, and nipples/breasts
Ice pack to perineum/episiotomy
Monitor bowel function
Assess for urinary retention and bladder distention
Provide nutrition counseling/teaching
Provide education regarding breast care
Provide education regarding breast or bottle-feeding techniques
Assess family interaction/bonding
Teach Kegel exercises
What is important to remember during a bladder assessment?
If the bladder is full, it will displace the uterus upward and to the side
A full bladder will prevent the uterus from contracting (involuting) and will increase the risk of hemorrhage
What are the common meds used during post partum?
- Acetaminophen and codeine for episiotomy
- Nonsteroidal anti-inflammatory drugs such
- as ibuprofen for cramping pain (afterpains)
- Stool softeners
- Benzocaine spray (Dermoplast) - perineum pain relief
- Tucks/Witch hazel pads - perineum pain relief
- Lansinoh breast cream
If mother is Rh negative, we must determine the infant’s blood type to determine if there is a Rh incompatibility
Cord blood is sent to the lab
If the infant is Rh positive, the mother must receive RhoGAM within 72 hours of birth
This will destroy antibodies she may have created and therefore protect her next fetus
Dose: 300 mcg I.M. or I.V.
Also known as German measles
Given to postpartum patients who are rubella non-immune (titer < than 1:10).
Not given while pregnant as it has teratogenic effects on the fetus therefore patients instructed not to get pregnant for 1-3 months after injection
Safe for breastfeeding mothers
Vaccine made of goose eggs…possible allergy?
Administered at discharge; 0.5 mL s.c. upper arm
What are complications associated with the postpartum period?
- Bonding issues
- Postpartum depression/“baby blues”
- Physical exhaustion
- Breast problems
What does the American Academy of Pediatrics recommend regarding breastfeeding?
exclusive breastfeeding for the first 6 months, then continue until 12 months
if weaned prior to 12 months, use iron-fortified formula
What are the benefits for the baby in breast feeding?
- Enhances GI maturation
- Less allergies/asthma
- Less SIDS
- Resistance to lymphoma and Type 1 diabetes mellitus
- Increased cognitive development
What are the benefits for mom in breast feeding?
- Decreased risk of ovarian, uterine, breast CA
- Decreased risk of postpartum hemorrhage
- Faster weight loss
- Some protection against osteoporosis
- Facilitates bonding
- – no supplies needed, less expense
- Requires an additional 500 calories per day
Describing imprinting (during breast feeding)
Breastfeeding should be initiated within one hour of birth because infant is in alert state
- This prompt feeding will “imprint” in the baby. Baby will remember how to breastfeed
- once it comes out of its sleepy state
Studies show that this prompt feeding facilitates greater breastfeeding success
What two hormones drop that trigger the release of prolactin?
estrogen and progesterone
What prepares the breast to release milk, and how is it produced?
Prolactin, and it is made in response to infant suckling so milk is constantly produced
What is essential to lactation? what is it responsible for...
Oxytocin, it is responsible for the let down reflex
What is included in the breast care client teaching for breastfeeding mothers?
- Shower daily but no soap on nipples; use lanolin cream after nursing
- Air dry nipples to prevent excess moisture; use bra pads to absorb leaking milk.
- Change frequently to prevent infection
Heat/massage should be used just before feeding to increase milk flow
Feed on demand. No time limitation. Not necessary to have infant nurse on both sides with each feeding
Mastitis is infection of the breast due to block milk duct/break in tissue. Antibiotics, moist heat, analgesics and continued breastfeeding are required
What is important to remember in breast care client teaching for bottle feeding mothers?
- Drugs are no longer used to dry up the milk. Adverse cardiovascular side effects
- Use supportive bra or binder for first 72 hours (around the clock) to prevent milk production in non-nursing mothers
- Cabbage leaves can be placed in bra; helps dry up milk; enzymes in cabbage cause milk production to end
- Ice packs to breasts decrease milk flow
What is important to remember about breast engorgement?
- Milk comes in but infant is not expressing the milk due to poor nursing technique
- Breasts become engorged with milk; breasts become very hard, making it difficult for
- baby to patch
- Pumping or hand expression of milk will help soften the breasts. However, pumping must
- be limited to 5 minutes; just enough to soften the breasts. Too much pumping will increase milk production and add to the engorgement problem
- For engorgement, use mild analgesics. Use cold compresses or ice packs to relieve engorgement discomfort (20 minutes 4 times per day)
- Frequent breastfeeding sessions will help decrease engorgement
What does pumping do?
When should it be done?
What are the storage requirements for breastmilk?
Stimulates milk production when the infant cannot nurse because of prematurity or illness
- Mother should pump for 15 minutes every 3-4
- hours while awake
Storage: Breastmilk is good for 5 days in refrigerator; good for 5 months when frozen
What are the phases of maternal postpartum adjustment?
Taking in phase --> Day 1. Patient very dependent. Emphasis on self. Requires much assistance. Desire to review birth experience
Taking hold phase --> Day 2 or Day 3. Lasts 10 days to several weeks. Less dependent. Patient more eager to learn about infant; providing more infant and self care. Desire to take charge. Still need for acceptance and nurturing by others
Letting go phase --> Independent. Providing all infant care. Emphasis shifts to entire family. Reassertion of relationship with partner. Sexual intimacy resumes. Resolution of individual role
Describe discharge teaching given to a new mom.
- C/Section patients to see their MD in 2 weeks
- Vaginal delivery mothers to follow-up in 6 wks
- Patient to report any of the following:
Foul smell from the vagina or C-Section surgical site
Abnormal bleeding/clots from vagina/C-S site
Constant uterine tenderness; prolonged perineal pain
Tenderness, swelling, warmth in the legs (DVT?)
Tenderness, pain, swelling in the breasts (mastitis?)
Temperature greater than 100.4 F/38 .0 C
What blood volume loss constitutes hemorrhage for a vaginal birth?
What blood loss volume constitutes hemorrage in a C-section patient?
Common in multipara women as uterus has lost its tone and ability to contract. Also seen in women carrying twins, large baby, polyhydramnios
Small section of placenta is retained or entire placenta has implanted deeply into the uterine wall (accreta). Continues to receive blood supply
Fundus will be firm but a steady flow of blood will continue until laceration is repaired. Common with large babies; precipitous deliveries
Due to broken blood vessel in perineum. Patient will report extreme pain, rectal pressure and an urge to have a bowel movement
What are the signs of postpartum Hemorrhage
- Excessive or bright red bleeding
- A boggy fundus that does not respond to massage
- Abnormal clots
- Persistent bleeding despite a firmly contracted uterus
- Increased pulse or decreased B/P
- Decreased level of consciousness
S/S of hypovolemic shock
What are the nursing interventions for a patient with a possible hemorrhage?
- Massage fundus for firmness, height, position
- Assess bladder for fullness/distention; empty bladder
- Assess for signs of shock
- Weigh peri pads to estimate blood loss (1gm=1cc)
- Monitor vital signs, urinary output, LOC
- Elevate legs 15-30 degrees
- O2 by mask at 8-10 L/min if loss is excessive
- Replace fluids and administer uterine stimulants
- Administer blood replacement as per MD orders
What is the pharmacologic management for a patient with a hemorrhage?
#1: Pitocin (oxytocin): 10-40 units/L IV or 10-20 U IM
#2: Methergine (methylergonovine maleate): 0.2 mg IM q 2-4 hr. Once stable, 0.2 mg PO Q 6 hr X 24 hours
#3: Hemabate (prostin 15M/carboprost): 250 mcg IM or intra-myometrically
- #4: Cytotec (misoprostol):
- 800-1,000 mcg rectally
What are the possible infections a woman can get during postpartum?
- Reproductive tract infections:
- Breast infections
Urinary tract infections
What thromboembolic disorders are possible during postpartum?
Deep vein thrombosis (DVT)
Pulmonary embolism (amniotic fluid embolism)
Disseminated Intravascular Coagulation (DIC)
What is DIC?
A form of clotting that is diffuse and consumes large amounts of clotting factors
Widespread external, internal bleeding or both
DIC is always a secondary diagnosis therefore must treat the condition that triggered DIC
What is the nursing interventions for DIC?
- REMAIN CALM!
- Vital signs q 1-15 min until stable
- Assess for shock with vital signs
- Fetal monitoring
Monitor uterine activity
Accurate I & O
Quantify blood loss; hang blood products
Explain situation to patient & family
Affects 50-70% of new mothers
Mild, temporary depression; weepy, may feel overwhelmed, insecure in own abilities
Occurs within a few days of birth
- Usually occurs around 4th week
- Unable to cope; social withdrawal
- Insomnia; fatigue
- May have thoughts of death/suicide
- Delusions, phobias
- Emotional lability
- Bizarre or violent behavior; mania
- Changes in appetite; sleep patterns
- May harm/kill infant
Statistics of Perinatal loss
Approximately 15 - 20% of all pregnancies end in miscarriage
- Miscarriages combined with stillbirths, newborn deaths and SIDS equals approximately 1/3 of
- all pregnancies
What are the nursing interventions for a patient who has experienced a perinatal loss?
Encourage verbalization of feelings
Discuss grieving process
Prepare patient for side effects of induction
Liberal use of analgesia and anesthesia
Offer opportunity to see, touch, hold infant
Prepare family for appearance of infant
Provide a Memory Box: tangible remembrances (lock of hair, gown, pictures, foot prints)
Discuss autopsy and explain benefits
Discuss plans for funeral or memorial services
Offer spiritual support from clergy
Offer baptism or blessing
Provide information re: support groups
Provide written grief materials
Follow-up with a bereavement counselor, social worker, clergy
What is "Resolve through Sharing"?
National perinatal loss support group
Picture of leaf or white rose placed on patient’s door to alert health care team of perinatal loss
What is the RN's best response to a perinatal loss?
What is the worst?
- Best RN response?
- “I’m so sorry for your loss”
- Avoid saying:
- “You can have another baby”
- “Your baby is in heaven”
- “It just wasn’t meant to be”
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