71 terms

N113 - Postpartum Assessment & Care

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Postpartum
From the delivery of the placenta & membranes to the return of a woman's reproductive system to its non-pregnant state - approx 6 weeks.
Involution
the process by which the uterus returns to its normal size.
Satisfactory involution
Firmness of uterus, rate of uterine descent & nature of lochia.
Normal rate of involution
1st day postpartum - at or slightly above umbilicus, 2nd day - at or slightly below umbilicus, 3rd day - 1 finger below umbilicus, 4th day - 2 fingers below, by 10th day - behind symphysis - not detectable
Delayed involution causes
A prolonged labor, general anesthesia, difficult delivery, multiple pregnancies, full bladder, infection, retention of placental fragments.
#1 postpartum concern
Hemorrhage
S/S of hemorrhage
Increase pulse rate, decrease in BP, excessive bright red bleeding, boggy uterus that does not respond to massage, unusual pelvic discomfort or back pain, cold, clammy skin
Critical levels for H&H
Hb <5.0g/dl & Hct of <20%, hemoglobin will decrease 1 to 1.5 g/dl & hematocrit will decrease 2-4% per 500 ml of blood loss
Early or immediate causes of hemorrhage
blood loss greater than 500 ml in first 24 hrs caused by uterine atony, laceration of the genital tract, retained placenta, adherent placenta.
Late causes of hemorrhage
Retained placenta and infection are the most common causes.
Lochia
the decidua (lining) which is cast off down to myometrium, a new endometrium is formed
Lochia rubra
Bright red, tends to clot, serosanguineous, becoming more serous and less bloody - last 1-3 days.
Lochia serosa
Dark red (or pinkish) to brond, sheds of decidua, looks less like blood - lasts 3-10 days
Lochia alba
Whitish/yellowish discharge - lasts 10-14 days, may last 3-6 weeks and remain normal.
Diastasis abdominis
Separation of the rectus abdominis muscles may occur leaving part of abdominal wall with no support except skin, subcutaneous fat, fascia & peritoneum.
Postpartum bathing
There is an increased risk for infection during postpartum.
Episiotomy
A surgical incision of the perineal body - assess using REEDA - redness, edema, echymosis, discharge, approximation
Laceration
A tear in the perineal body which occurs in varying degrees.
1st degree laceration
tear through skin & structures that are superficial to muscle
2nd degree laceration
extends through perineal muscles - much like an episiotomy
3rd degree laceration
continues through anal sphincter muscle
4th degree laceration
involves anterior rectal wall
Sulcus tear
tear into the tissue of the vagina
Bladder function after delivery
Pt should void within 6-8 hours following delivery, check for bladder distention if less than adequate amount voided - retention with overflow
Bowel dysfunction
Delay in bowel function can be due to loss of abdominal muscle tone, fear of pain, sluggishness due to progesterone effect on smooth muscle function.
Dietary recommendations
Vaginal deliveries can have normal diet, have increased thirst due to fluid loss & medications. C-sections start on clear liquids until bowel sounds or flatus are present.
Vital sign monitoring after delivery
Q15 minutes for 1st hour, q30 minutes for 2nd hour, q4 hours for 24 hours then q8 hours.
Standard vital signs
Temp, resp, pulse, BP, lochia, fundus & appearance of sutures
BUBBLE HE
Breasts, uterus, bladder, bowel function, lochia, episiotomy (or laceration) Homnam's sign, emotional status.
Breast assessment
Are they soft, firm or filling? Any discharge - type & amount, Nipples cracked/lesions? Unusual contour?
Uterine assessment
Is it firm? Is it descending? Location & position in abdomen
Bladder assessment
Assess for position and size. Teach S/S of infection, teach proper pericare
Bowel assessment
Check for flatus/bowel sounds, rectal pressure. Teach need for extra fluids, fiber
Lochia assessment
Assess for amount: scant, light, moderate, heavy, excessive, assess for odor, clots
Episiotomy or laceration assessment
Assess for redness, edema, echymosis, discharge & approximation
Emotional assessment
Is the mother dependent or independent? Is she depressed, is she bonding with the baby, does she understand whats going on?
Antepartum
The time between conception and onset of labor, used interchangeably with prenatal
Intrapartum
The time between the beginning of labor and the birth of the infant.
Puerperium or postpartum
Time from birth of infant until woman's body returns to essentially prepregnant state.
Para
The number of pregnancies in which the fetus has reached 20 or more weeks gestation when they are born regardless of live or still born.
Abortion/miscarriage
Birth that occurs prior to the 20 weeks, either selective or spontaneous. Therapeutic - done to save mother or non-viable fetus.
Preterm/premature labor
Labor that occurs after 20 weeks but before completion of 37 weeks.
Term pregnancy length
A pregnancy from the beginning of 38 weeks of gestation to the end of 42 weeks
TPAL
TPAL replaces para & gives more information. T = term infants, P = preterm infants, A = abortions (spontaneous or selective), L = currently living children
Still birth
A baby born dead at 20 or more weeks gestation.
Neonate
First 28 days after birth.
Viability
Capacity to live outside the uterus - about 22-25 weeks gestation.
Placenta accreta
Slight penetration of placenta into the myometrium
Placenta increta
Deep penetration of the placenta into the myometrium
Placenta percreta
Perforation of the uterus by the placenta.
Hydroamios & macrosomia
Hydraminos is too much amnionic fluid, macrosomia is a large baby. Both stretch the uterus more than normal and make it hard for the uterus to contract after birth.
Hematoma cause
There is an injury to a blood vessel, vulvar, vaginal, subperitoneal causing a collection of blood in the pelvic tissue, can lead to postpartum hemorrhage.
S/S of a hematoma
Vulvar - most common & most can be seen, Upper vaginal - difficulty voiding due to pressure on urethra or meatus, Upward - severe lateral uterine pain, flank pain, abdominal distention. May have S/S of shock without blood loss & a well contracted uterus.
1st sign of infection
Presence of a fever of 100.4
Neonate & infection
Leading cause of newborn sepsis & meningitis, infant infected through vaginal birth, can lead to death or severe neurological damage. Routine screening done at 32-36 weeks. Ampicillin or gentamycin can be given during labor.
Metritis
Infection of the muscle of the uterus
Endometritis
Infection at the placental site
Parametritis
Infection of the pelvic connective tissue.
Salpingitis & ooporitis
Infection of the tubes & ovaries.
Thrombophelpitis
An infection of the lining of a vessel in which a clot attaches to the vessel wall.
Pulmonary emboli symptoms
Sudden onset of SOB, chest pain, tachypnea, dyspnea, apprehension, cough, hempotysis, diaphoresis, fever, circumoral cyanosis.
Amniotic fluid embolism
A small tear in the amnion or chorion high in the uterus allows fluid to enter maternal circulation.
Disseminated intravascular coagulation - DIC
The coagulation sequence is activated by injury to the epithelium, or by bacterial particles or other foreign material. The result is disseminated clotting causing organ damage due to small clot occluding capillaries and consumptions of clotting factors.
Psychological adjustment stages
Taking in, taking hold and letting go.
Taking in
Consists of days 1-3, pts are passive & dependent, preoccupied with own needs, talkative, identifying and interpreting infant, gentle finger touch.
Taking hold
Consists of days 3 to 2 weeks. Pts resume control of life, concern with control of body functions, worry about quality and quantity of breast milk and ability to feed baby.
Letting go
Accept and realize the physical separation of infant and relinquish role of childless individual. Challenge - extreme exhaustion of night time care and sleep deprivation, anticipatory guidance needed regarding the realities of motherhood.
Postpartum or baby blues
Can occur 1-2 weeks after birth, often peaks around 5th day and subsides by 10th day - believed to be related to hormone levels. Exhaustion is rated as one of the top causes.
Postpartum depression
Symptoms persist longer than 2 weeks and intensify.
Elevated temp causes
A temp elevated to 100.4* in the 1st 24 hours post delivery can be due to exertion & dehydration.
Mastitis
An infection of the breast tissue. More common in breast feeding mothers.
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