Midterm review: 1. Postpartum changes: Normal physical changes Involution: - Measured by assessing fundal height - 1 cm/day - Promoted by breastfeeding, Pitocin - Inhibited by prolonged labor, retained placenta, anesthesia, blood clots, full bladder, and boggy uterus. BM within 4-7 days, medications may alter this like opioids that slows down BM, sometimes fear Hemorrhoids: cold compress, topical creams and sprays, pain medications, witch hazel Eye hemorrhage: from the pressure of pushing Hair loss Afterpains: - Contractions - First 4 days - Oxytocin action compress blood vessels - Multiparous women more pain, closely spaced children - Breastfeeding - Ibuprofen for pain Cardiovascular: - High plasma fibrinogen levels - Tachycardia (slightly 100-110) Vital signs: - Temp elevated in first 24 hrs - Tachycardia followed by bradycardia - Elevated respirations r/t pain - BP normal - O2 normal Exfoliation: - Necrotic tissue sloughing off - Preserves fertility Lochia: - Vaginal discharge - Rubra, serosa, alba Episiotomy: - Takes about a month to heal Period after 7-9 weeks. If breastfeeding, around 3 months (ovulation is not skipped-can still get pregnant). Vagina: -Swollen, bruised -Kegel exercises, strengthen pelvic floor -Lactation might lead to dryness for 6 months PP Weight loss: -Immediate 12-14 lbs, 5-15 lbs in early PP due to diaphoresis and urinary excretion - Back to pre-pregnant weight in 6 months GI system: - Hungry - Constipation Musculoskeletal system: - Abdomen is soft and saggy - Aches/pains in back and shoulders - Swelling due to IV fluids Urinary system - Issues with voiding - Transient glycosuria, proteinuria, ketonuria Integumentary: - Striae (they fade over time) - Diaphoresis Breast: - Full, heavy 2. BUBBLE-HE assessment Breast: - ask pt. how breasts are feeling - compare left and right - check skin and color, warmth - check nipples and areola : everted, inverted, flat, if any bruising, baby might not latch correctly Uterus: - Have patient flat on back - Support the abdomen with one hand and feel the uterus/fundus with the other: look for the fundus where it supposed to be. Firm, firm with massage or boggy (bad-possible hemorrhage). If deviated, bladder might be full, mom should void every 2-3 hrs. Bladder: - Ask when was last void, try every 2-3 hrs - Bleeding less, heal faster, more healthy Bowels: - Listen to bowel sounds - With normal vaginal delivery, regular bowel sounds - If C-section, may be hypoactive after anesthesia - When was the last time eat/drink, give mom food-> need calories to feed baby and heal Lochia: - Vaginal discharge that contains: blood, mucus, parts of necrotic decidua. Should not have odor, or menstrual flow odor. - Check the pad, ask when last time they changed was. Observe amount and compare to time pad changed. Change pad every 2-3 hrs to decrease infection risk. Wash hands before and after. - Rubra: last 1-3 days, bright red blood. Heaviest during 1st 2 hrs after delivery, may contain small clots - Serosa: pink or darker older blood color, may last up to 27 days, no clots - Alba: yellowish white discharge, starts on day 10 and can last for 6 weeks - May be more in the morning and with exertion - Ask about blood clots, size of nickels, dimes are normal, size of egg is not. - SHOULD NEVER GO BACKWARDS Episiotomy: -It’s not common practice anymore - Assess any lacerations: redness, ecchymosis, edema, discharge, approximation. Sutures are dissolvable. Homan’s sign: - Postpartum is a hyper coagulative state, check for DVT - Lift and support the leg under knee and sharp dorsiflexion, ask for any pain in calf (if yes + Homan sign) - Look for redness, swelling or heat - Check pedal pulses +2 is normal Emotional state: - How is the mother doing, watch out for negative reactions and lack of bonding - Support system: father of child, family support - 3 stages (Rubin): taking in, taking hold, letting go. Taking in is all about mom, taking hold is about the baby and how to care for it, letting go is usually at home. - Encourage mom, help with infant care. RUBIN PHASES: - Taking in: starts after birth and last up to 2 days, mom is passive and dependent and concerned with her own needs (pain, rest, food), talks about birth, lets others care for baby, not a good time to educate. - Takin hold: mom is ready to be more independent and interested in taking care of baby. Mom is concerned about taking care of self and baby. Best phase for education. - Letting go: Mom assumes her position in home, accepts maternal role, demands placed on mom can lead to mild depression 3. Postpartum danger signs Fever >100.4F, elevated temp. is okay after delivery but fever is not Frequency, urgency, pain with urination. Unable to urinate. There is an initial loss of sensation to feel like urinating but being unable is not normal. SOB or chest pain (watch out for PE and heart attack because of clots) Foul smelling lochia (smell may indicate infection) Heavy lochia (a pad an hour for 2 hrs) Returning of lochia rubra after it has been serosa or alba already Large clots (bigger than an egg and after 3-4 days is abnormal) Swollen, red , painful calf area (DVT) Swelling, redness, heat, discharge, blood from incision site No BM 4-7 days PP Visual disturbances Severe headache (BP issue, spinal issue) Flu like symptoms (mastitis-red, hard, painful area in breast) Signs of PP depression (crying for no reason, harm to self or infant POSTPARTUM DEPRESSION: Causes: Hormonal drop, sleep deprivation, anxiety Risk factors: depression, bipolar disorder, mom/baby has health problems, multiples, little or no support, other troubles like money, IPV S/S: mood swings, excessive crying, overwhelming fatigue, withdrawing from friends/family, irritability/anger, anxiety/panic attacks, abnormal decrease or increase in appetite, no longer interested in things mom enjoys, decrease in focus/concentration, feeling worthless, thoughts of harming self/baby D/x: 1st year of childbirth Edinburgh postnatal depression screen POSTPARTUM HEMORRHAGE: Blood loss >500 ml vaginally, >1000 ml c-section Classifications: -Early: in first 24 hrs Atony Lacerations Hematoma -Late: 24 hr- 6 weeks Hematoma Subinvolution Retained placenta Risk factors: - Macrosomia - Polyhydramnios -Multiparity/high parity - Operative vaginal delivery (forceps, vacuum, episiotomy) - Pitocin - Precipitous labor - Obesity S/S and management: o Atony: boggy fundus, saturating peripad within 15 mins, may have clots, hypotension, tachycardia. Interventions: Meds: Pitocin, methylergonovine, LR. Fundal massage, empty bladder, blood and/or platelet transfusion, H+H, 2nd IV, emotional support.
