postpartum

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Prittyrick
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postpartum
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2015-04-05 09:40:19
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  1. meds used during post partum
    • oxytocin- contraction
    • misoprostol (cytotec)- used for postpartum hemorrhage
    • methylergonvine, ergonovine meleate, carboprost tomethamine- causes hypertension (used for postpartum hemorrhage)- contrast vascular system think of BP if high don't use
    • Analgesia
    • NSAIDs
    • - ibuprofen
    • - ketketorolac (torodol)- IV bi motrin
    • Opiates
    • - Oxycontin
    • - Oxycodon
    • Acetaminaphine (tylenol)
    • Stool softerner
    • - colace
    • Laxative
    • - docusate (ducolax) suppositories fiber
    • Immunization
    • - Rhogram
    • - MMR
    • - tdap (you can give pernatally)
    • - flu etc
  2. oxytocin (pitocin)
    • used immediately post partum
    • to contract the non gravid uterus and prevent hemorrhage
    • Administer
    • - 10-20U of oxytocin mixed with 500-1000ml LR main IV x 1 liter (hosp policy) (way bigger then what use during labor)
    • - usually administer at 125ml/hr
    • - assess for hypertension and pain
    • - water intoxication- cause hypotension, headache, LOC
    • - antidiurectic
  3. Initial postpartum assessment
    • Vital sign (BP, P, RR):
    • - during the first hr q 15 mins
    • - during the second hr q 30min
    • - hourly x2
    • - during the first 24 hr q 4 hours
    • Temperature
    • - every hr of the first 4 hr, q 4hr for the first 24 hours, then q 8 until they leave
    • pain is the 5th vital sign do this when you check vs
  4. Initial assessment other
    fundus, lochia, perineum, incision
    • Uterus fundus (same as vital)
    • - firm or boggy, midline, displaced up left or right,
    • - assess bladder distension
    • Lochia (same of VS)
    • - initial rubra moderate amount
    • - assess amount, odor (fleshy smell), color, pressence of clots
    • Perineum
    • - assess q hr for the first 4hr
    • - REEDA
    • Incision for c-section
    • - assess q hr for the first 4 hr
    • - REEDA
  5. Initial postpartum I&O, Breast feeding
    • Monitor I&O closely
    • - Vag delivery: measure voids according policy
    • - c section have foley catheter for the 1st 12-24 (some places are trying to do this sooner 6-8 to avoid UTI)
    • Maintain IV administration as order
    • - Vaginal- unstable
    • - C-section- per facility protocol. approx 24 hr (esp duramorph given 24 hrs)
    • Encourage breast feeding immediately after birth
    • - helps to release oxytocin from the pituary gland
    • - promotes contraction of the uterus
    • - promotes bonding
    • - initiate nutrition of the NB to aid in maintaining glucose
  6. Postpartum physiological adaption CV
    • CV changes occurL
    • - decre in blood volume due to blood loss and diaphresis
    • (compensated by elimination of plancenta and reduction of the uterus)
    • - cardiac output- increa for the first 24-72 hr (watch out for congestion)
    • possible orthstatic static hypotension within the first 48hr postpartum r/t to organ engorgement
    • VS
    • - BP, RR, no change P, increase initially T- first 24 hours (bc of trauma, dehydration, labor for a while)
    • Norm blood loss
    • vag- 500ml
    • c-section 1L
    • gets displaced
  7. Postpartum physiological adaption Labs
    • RBC: decr production, Hgb and Hct decr slightly- usually normal only with hemorrhage
    • WBC: elevated 4-6 after delivery
    • - usually related to trauma
    • - complication and diagnosis of infection
    • Coagulation levels incre during pregnancy and last 2-3 weeks postpartum
    • - assess legs for DVT, swelling, redness, warmth
  8. Postpartum physiological adaptions Endo,
    • Hormonal changes: De
    • Decre estrogen
    • - breast engorgement, diaphoresis, diueris, vag dryness, discomfort with intercourse
    • Decre Progesterone
    • - increase in muscle tone (moms feel stronger)
    • Absent placental hormone
    • - reversal of diabetogenic effects resulting in lower blood glucose (you lose HPL which caused resistant to mom)
    • - oxytocin levels high if breast feeding milk let down
    • - prolaction: levels are high if breast feeding (milk production)
    • - relaxin: decre pre pregnant function of joints GI/GU system
    • DM will go back to normal insulin
  9. PP physiological adations respiratory and msk
    • Respiratory:
    • - return to pre pregnant state rapidly after birth
    • Musculoskeletal system:
    • - stabalization of joints with decreasing relaxin level, adjustment to change in posture
    • - separation in rectus abdominis muscle- diastasis recti.
    • - incre fatigue related to decr relaxin and decr progesterone, joint pain and change in body mechanics to adjust posture change
  10. PP physiological adaption GI, integumentary system
    • Gi system:
    • returns to pre pregnant state quickly bc decre in progesterone and gravid uterus no longer fills abd cavity
    • - decre bowel tone
    • - decre perstalsis - decre bowel sounds
    • - decre muscle tone
    • - perineal pain (vag delivery) fear to have BM
    • - incre hunger or thrist
    • Integumentary system
    • - pigmentation (mask gone), stretch marks, hair loss
    • - profused diaphoresis this is common during the early postatum period one of the most noticable in this system
  11. PP physiological adaption GU
    • Voiding sensation affected by
    • - perineal laceration
    • - sweating bruising the peritoneum and tissue surrounding urinary meatus
    • -hemotomas
    • - oxytocin
    • - decre bladder tone due to regional anesthesia
    • Risk for incomplete emptying, bladder distension, difficulty voiding, and urinary retention (risk for infection)
    • (assess for frequent voiding of small amount)
    • diuresis
    • - diuresis begins in 12 hr after birth and goes on for 1 week postpartum
  12. PP physiological adaptions reproduction
    • Uterus
    • -- Involution: contraction of muscle fibers. bringing uterus back behind pelvic bone in 6 weeks
    • -- uterine result in after birth pain
    • - Cervix: now appearing like a jaggered split openning
    • - vagina: eventual thickening and return of rugae
    • - ovulation- depends on infants feeding method- fsh incre bc of high prolactin level
    • perinum- encourage kegel exercise
  13. Normal Involution
    • the uterus returns to its normal size by gradual process of involution
    • at birth- at the umbilicus
    • at 12 hour- maybe 1cm above umbilicus
    • usually uterus descend 1cm/fingerbreath a day
    • if not involutating there maybe some contents in there
  14. factors that facilitate and inhibit involution
    • facilitate:
    • complete emptying of aminiotic membrane and placenta at birth
    • complication free labor and birth
    • breast feeding
    • early ambulation
    • good nutrition
    • Inhibit
    • prolonged labor difficult birth
    • everything didn't leave when delivery happened
    • uterine infection
    • over distension of uterine muscle
    • full bladder
    • anesthesia
    • close childbirth- one after the other
    • multiparity
  15. Lochia
    • COCA, color, odor, consistency, amt
    • Rubra- red, 1-3 lasting, blood fragments of decidua and mucous
    • serosa- pink 3-10, blood mucous and invading leukocytes
    • alba- white 10-14, largely mucous, leukocytes count high
    • scant 1-2 in stained 10ml
    • light/small 4in (10-25ml)
    • large/heavy- pad saturated in a hour
    • episotomy- REEDS
  16. PP Physiological changes Ovulation menstruation
    • interplay of hormones: estrogen, progesterone, prolactin, oxytocin
    • Non lactating women- return to menstruation 7-9 weeks after birth
    • lactating women return depending frequency and duration: between 2-18
  17. Episiotomy
    • used to make room for the head
    • make sure it is not infected and it is approx.
    • tearing to the 3rd or fourth degree is bad.
    • Midline incision
    • Medioisteral incision
  18. Perineal laceration
    • based off degree of tear
    • 1st degree- skin and superficial structure no muscle
    • second- extends thru perineal muscle
    • 3rd- extends thru anal sphincter muscle
    • 4th- contines to anterior rectal wall (nothing in the rectum)
  19. Nursing intervention for the perineum
    • application of cold and heat:
    • ice for the first 24 hr- vasoconstrict
    • peribottle-cleans perineal area may spray while urinating if not hurting
    • sitz bath with warm water maybe used for comfort.
    • - disposable small whirlpool bath that is used to clean perineal, promote comfort and healing
  20. Postpartum danger signs
    • VS
    • -Temp- > 100.4 longer than 24hr
    • Pulse
    • - tachycardia
    • BP
    • - decre or incre- always compare baseline
    • Respiration
    • - tachyapnea, bradyapnea, SOB
    • - diminished breath sounds, too much fluid, pulmonary edema- rales
    • Pain
    • - assess type of pain, duration, location, severity
    • - pain unrelieved by treatment (hematoma, reassess)
  21. additional postpartum danger signs
    • foul smelling lochia, unexpected change in color or amount. apprearance of clots
    • visual changes such as blurred vision, headaches, spots,
    • calf pain with dorsiflexion of foot
    • (advice mom not to sit for longer periods)
    • swelling redness, discharge at episiotomy site
    • dysuria, burning, incomplete emptying of bladder
    • SOB, difficulty breathing
    • depression or extreme mood swings
  22. Nursing Management: Assisting with elimination
    • Bladder
    • - encourage to void
    • - due to void in 6 hr
    • -palate for distention
    • - if voiding less than 100-150ml question retention w/overflow
    • - may need catherization
    • Bowel
    • - stool softener doucosate
    • - laxative
    • - ambulation
    • - increasing fluid (8-10 glasses/day) increase fiber
  23. Nursing management rest
    • Promoting activity rest and exercise
    • - early ambulation
    • - exercise program- kegel work
    • - early ambulation to decre risk of clots, improves strength
    • - encourage regular exerise
    • Promote resting:
    • - rest periods
    • - postpartum fatigue is common during early times and may continue for weeks and month
  24. Nursing management self care and safety
    • Assisting with self care
    • - preventing infection during postpartum
    • - keeping it clean
    • Safety
    • - orthostatic hypotension
    • - back to sleep
    • - infant in crib if mom sleepy
    • - check id if anyone is coming to take baby
  25. engorgement and breast feeding
    • comes 3-5 days after
    • if engorged harder for baby to feed
  26. nursing interventions for lactating women
    • wear a well fitted bra 24hr/day during this time
    • emphasize good hand hygiene
    • allow infant to nurse on demand (8-12 times)
    • empty both out
    • massage breast during feeding to help come out
    • mild analgesic for pain
    • Engorgement
    • - cool compression between feeding, warm compression or shower prior to feeding
    • - cold cabbage leaves in bra for 45 mins
    • - sore nipple apply small amount of breast milk and let it air dry
    • - cracked nipples- cream or shield
    • - adequate fluid and calories to support
  27. Nursing intervention for non lactating mom
    • wear well fitted bra 24 hrs until engorgement ceases
    • avoid breast stimulation
    • avoid running warm water on breast for long periods
    • cold cabbage leaves inside bra45 min
    • cold compresses- 15-20 on 45 off
    • mild analgesic (antiinflammatory for pain)
  28. Nutrition
    • additional calories 500 cal for breast feedings
    • calicium + 400mg= 4 or more milk
    • good diet with all four groups
    • high protein (20) to assist with healing and tissue repair
    • 2-3 liters a day food or beverage- no soda
  29. baby friendly hospital
    • rooming in-
    • encourage breast feeding
    • - trained staff there to help 100
    • - breast feeding within 30 mins of delivery
    • Observe bonding
    • - attachment- enface position
    • - factors affecting attachement- sick baby
    • - attributes of attachment
    • psychosocial and maternal adaption
  30. maternal pyschological adaption
    • taking it in phase- dependent
    • - first 24-48 hr
    • - focus on meeting personal needs
    • - rely on others for assistant
    • - excited, talktative needs to review birth experience
    • Taking hold phase (dependent to independent)
    • - begin 2-3
    • - focus on baby care and improving on their skills
    • - want to take charge but need acceptance from others
    • - wants to learn and practice
    • Letting go phase (interdependent)
    • - focus on the family unit
    • - resumption of role-
    • - not seeing the baby as apart of them
  31. PP blues
    • baby blues
    • caused by rapid decre of estrogen and progesterone
    • transient no treatment
    • symptoms appears on the 3rd -4th day
    • characterized by anxiety irritabilty
    • insomonia, crying, loss of appetite sadness
    • self limiting
    • resolves in 1-2 weeks
  32. Preparing for discharge
    • VS normal range
    • Lochia approriate COCA
    • norm hgb and hct
    • fundus firm, urinary good
    • ABO groups and Rh status known- rhogram given if neccessary
    • surgical wounds are healing no signs of infectin
    • mobility and nutrition are normal
    • self care of infant are known and demostrated
    • mother is aware of possible complication
    • mom immune status are reviewed. immunization given
    • smokers will get pneumonia vaccine
  33. education of mother
    • kegel exerise
    • pelvic tilt excerise to strengthen back
    • discourage heavy lifting
    • limit stair climbing
    • no driving for 2 weeks or while on opiods
    • breast feeding- pain meds cross over in milk in small amounts
  34. sexuality and contraceptive
    • sexual can begin when brigh red bleeding has stop, no swelling in the periteum episiotomy and laceration healed
    • when pain decre from c section
    • usually 3-6 weeks postpartum
    • contraceptive needs:
    • use condoms or spermicides until you figure what is best
    • postpartum women should not be prescribed combined hormones for 21- hx of DVT
    • or 42 days with hx of DVT

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