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Chapter 20 Postpartum Adaptations 7
Terms in this set (75)
What changes in blood pressure are expected in the post partum period?
BP same, if low could be a hemorrhage. If preeclampsia and blood pressure stays, must be treated. Could lead to HELLP syndrome.
If the infection was present before delivery, do mother and baby need to be separated?
What is the estimated blood loss for a C-section and for a vaginal delivery?
c-section - 1000 ml or less, vaginal 200-500 ml.
What are normal hemoglobin, hematocrit, wbcs post partum.
Hemoglobin and hematocrit should return to normal in 6-9 weeks. Wbcs 25,000-30,000. If no temp, considered nonpathologic leukocytosis.
What does increased coagulation in a post partum patient lead to?
thromboembolism - at greater risk for 12 weeks
What happens to the excess fluid volume in a post partum patient?
eliminated through diaphoresis and diuresing - especially at night in the first week.
How much will hct decrease for every 500 ml?
How much does C-section increase risk for infection?
Name some things that incrase the risk for infection in the post partum period.
prolonged labor, rupture of membranes prior to 24 hours before birth, difficulty removing all of placenta, prolonged labor that ends in C-section - up 35% increased risk, frequent vaginal exams, use of fetal spiral electrode, DM, HTN, immunocompromised, substance abuse
What are some signs of infection with vaginal delivery and C-section?
vaginal - fever, chills, increased HR, dysuria, uterine tenderness.
C-section - discharge from incision, foley increased risk.
What are some causes of infection post partally?
endometrial linging exposed, increased alkalinity of reproductive tract
When is the majority of weight lost in the post partum period?
10-12 pounds in the first week
When does a woman typically return to prepregnant weight?
6-8 weeks, low weight gain will return faster. Initially weight loss greater in women that breast feed. At 6 mos, should be no difference in breast feeding women.
What is the breakdown of weight gained during pregnancy?
11 lbs- fetus, placenta, fluid
2 - uterus
4 -increased blood volume
3 - breast tissue
5-10 - maternal stores
What makes an adolescent at greater risk for infection in the post partum period?
cephalopelvic disproportion, increased chance of drug abuse
Describe involution of the uterus.
Return to prepregnant size. the size of an orange. Will go from 1000g to 300 g in 3 weeks.
What happens to the decidua of the uterus after birth?
Sloughs off as lochea allowing new endometrium to form. Placenta site heals by exfoliation in about 6 weeks,
What is subinvolution?
Failure of the uterus to return to normal size and condition at normal rate.
How does the fundus change position after birth?
after delivery - moves to halfway between umbilicus and symphysis pubis. 6-12 hours after birth at the level of the umbilicus Descends 1 cm each day. After day 10, no long palpable.
What should you be aware of when palpating the fundus?
inverting the uterus, always use two hands and apply counter pressure.
What should you be aware of in a C-section patient when palpating?
Pain after epidural wears off.
How long does it take for uterus involution to complete?
Why is palpation of the fundus done?
to asses for location of the fundus. make sure fundus is contracted and to expel blood clots.
How can breastfeeding aid in involution of the uterus?
Oxytocin causes the uterus to contract - can be painful .
What are some factors that interfere with involution?
prolonged labor, anesthesia, excessive manipulation during delivery, grandmultiparity, overdestension, full bladder, retained or incomplete expulsion of placenta, infection, polyhydraminos, twin pregnancy.
What changes are seen in the cervix?
from a dimple to a lateral slit
What changes are seen in the vagina?
size decreases in 3-4 weeks. Back to normal in 6 weeks. The breast feeding woman will have less rugae and may have vaginal dryness.
What changes are seen in the perineum?
healing of episiotomy or laceration from 3 weeks up to 6 months.
When does menstruation return?
nonbreast feeding - 6-10 weeks, first cycle is nonovulatory. Breastfeeding - with length of breastfeeding. If not breastfeeding exlusively period may return.
How does the abdomen change in post partum?
loose and flabby. will regain tone in 2-3 months. possibly diastasis of recti - strain, cough, sneeze - may see a bulge
How does GI change in post partum?
bowels slow, episiotomy or lacerations may delay BM, hemorrhoids
How does the urinary tract change in post partum?
increased bladder capacity, trauma, risk of overdistension, increased output, 2000-3000 ml of extracellular fluid to be eliminated
What can cause blood to appear in the urine of a C-section patient?
trauma from retractors.
What thermal changes are seen in post partum?
chill immediately after birth, pelvic nerves, maternal adrenaline, epidural effect, loss of fluid. No elevated temp. Warm blankets help. Diaphoresis fluid elimination via perspiration cools.
What does BUBBLEHER stand for?
Breasts, Uterus, Bladder, Bowels, Episiotomy, Homan's sign, Emotional, Rhogam/Rubella
What happens to the breasts of a breastfeeding woman?
"let down" or milk, assess condition of nipples, suggest good support bra, record nursing pattern, check for symptoms of mastitis - chills, fever, redness of breast, streaks, engorgement.
What happens to the breasts of a nonbreastfeeding woman?
good support bra needed, refrain from nipple stimulation, cold packs, cabbage leaves.
During pregnancy, prolactin rises from 10 ng/ml to 200 ng/ml. 1-2 days - colostrum, 2-3 days - engorgement, 4-7 days - milk production. As infant feeds, milk production increases.
Where will the fundus of the uterus be at 2 hours after birth?
Where will the fundus of the uterus be at 2 days after birth?
2 cm below umbilicus.
Where will the fundus of the uterus be at 4 days post partum?
4 cm below the umbilicus
failure of the uterus to return to the usual size at the normal rate. uterine atony - smooth muscle not contracting. Uterus described as boggy.
What are the causes of subinvolution?
full bladder, retained placental fragments, infection, multiparity, large babies or twins, prolonged labor
What are some nursing interventions for subinvolution?
have patient void regularly, massage fundus, have patient breastfeed, skin to skin. Can give pitocin, methergine, hemabate
What are some contraindications for methergine? Whats a side effect of hemabate?
hypertension, cardiovascular disease. diarrhea.
What kind of voiding is expected in post partum?
Due to void as quickly as 1-2 hours after delivery. Want voids to be 100 ccs or greater. Put hat in toilet and collect 3 times. Mom should diurese 600-700 ml within 24 hours, if not the straight catheter is needed.
What are some risk factors for a UTI?
history of UTI during pregnancy, trauma at delivery, edematous perineum.
What can be found in a post partum urine analysis?
positive nitrogen due to sloughing off of uterine lining- first 10 days. mild proteinuria 1+. Acetone 1+ in diabetics or prolonged labor.
When is bladder tone restored?
What can be found assessment of bowels?
Assess for sounds in all 4 quadrants. Increased flatus, constipation, mild to complete paralytic ileus can cause perineal rectal discomfort, post partum fluid loss. Pain with BMs - can give colace. Assess medications which can cause and relive bowel problems. Assess for hemorrhoids.
What are the 3 types of lochia seen?
Rubra - 1-3 days, deep red with clots the size of a nickel
Serosa - 4-10 days - pinkish, contains serous exudate
Alba - 10-24 days, up to 86 - white/gray
What is lochia like?
musty but not fowel odor, moderate quantity, shouldn't gush. Expect 4-6 peripads per day- change everytime you go to restroom. if weighed 1 g = 1 ml of blood
What is an episiotomy?
a surgical incision of the perineal body.
How can you assess an episiotomy?
Assess with patient in Sim's position. Can have some redness and edema with healthy healing.
R - redness
E - ecchymosis
D - drainage
A - approximation - no separation of incision
What can the patient be educated about regarding perineum care?
wash hands before and after cleansing and changing pads, use pericare squeeze bottle, cleanse from front to back, apply pad from front to back, change pad with each void or defecation, assess amount and character of lochia
What kind of nursing care can provided to the perineum?
apply ice pack first 2-3 hours to decrease edema and cause vasoconstriction. ice should be applied 20-30 min then take off 20 min. Sitz bath cool or warm, dry heat, topical applications.
Describe how Homan's sign is used?
used to assess for DVT. Edema, unilateral in lower leg calf area. dorsiflex the foot and check for calf pain. Examine calf for hardness, nodules and pretibial edema. Not used as much anymore - could lead to embolus and inspecting with light palpitation works just as well.
Describe the taking in period.
first few hours - Mother is concerned with her own body, relives the birth experience, dependent on others, sense of disappointment, less interest in child.
Describe the taking hold period.
24-48 hours after birth - concerned about parent skills and success, very receptive to teaching, need to feel confident in infant care.
Who came up with the theory of maternal adaptation?
What is involved in parent-child attachment?
two way bond between parent and infant, reciprocity is the synchronous process you want to see, bonding - soon after birth, touch, eye contact, voice, odor. En face position - mother and newborn positioned 8 inches apart and meet eye to eye.
What is engrossment?
preoccupation by fathers to newborn
Describe postpartum blues.
onset within 1 week of delivery, lasts a few weeks to 6 weeks. 50-80% incidence. mood swings, tearful, fatigue, insomnia
Describe postpartum depression.
onset anytime in the first year, 10-15% incidence. symptoms of clinical depression. duration about 6-9 months. higher risk in those with previous diagnosis
Describe postpartum psychosis.
1-2 per 1000 births. 10-50% recurrence in next birth, 2-10% risk of infanticide, agitation, confusion, hallucination, delusion, need hospitalization. anti-psychotics, removal of infant, social support
What can lead to post partum depression.
previous episodes of depression, family history of depression, dissatisfaction with current relationship, stress r/t childcare, social support, financial problems, self-esteem, infant temperament.
What is the route and dose of rhogam? When should it be given?
300 ug IM within 72 hours of delivery. Also give at 28 weeks gestation if mother is rh negative. Also give after each spontaneous or induced abortion, ectopic pregnancy, amniocentesis, or maternal trauma
Explain rhogam use.
blocks production of antibodies - coats fetal cells in maternal circulation so maternal immune system doesn't produce antibodies for cells not recognized as an antigen.
Explain rubella vaccine use in post partum period.
not given in pregnancy. Give post partum if titer is less than 1:10. Patient must sign consent - live virus. Pt must not get pregnant for 3 months. Given at discharge.
What is post partum sexuality like?
Can have sex 3-4 weeks after delivery. if breast feeding. vaginal lubrication may be decreased, discuss contraception options, kegel exercises may help with vaginal relaxation.
What should be assessed for a post partum adolescent?
readiness to learn, give clear instructions, demonstrate care have return demo before discharge, group classes with peers, follow up via home visits
What are the post partum family needs?
encourage private time for family and baby, skin to skin contact if possible, assess family needs and child bearing goals, include siblings in education.
What temp is expected in postpartum?
Temp as high as 100.4 in first 24 hours. If greater than 100.4 on 2 consecutive checks, check for infection.
What heart rate is expected postpartum?
Pulse will decrease as low 50 bpm. Returns to normal 6-10 days. If above 100 bpm - could be infection.
What respiratory rate is expected postpartum?
60-100 - normal
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