CHAPTER 12: Postpartum Physiological Assessments and Nursing Care

Respiratory system - LO 1

-Assess resp rate, breath sounds for pulmonary edema >Women at risk for pulmonary edema: received oxytocin, large amounts of IV fluids, tocolytics, multiple birth, infection, preeclampsia, bed rest

Uterus Afterpains - LO 1

- moderate to severe cramp like pains related to uterus working to remain contracted and/or increase of oxytocin released in response to infant suckling. -Occur within first few days and decrease 3 days after delivery -occur more commonly with multiparous women and increase with each additional pregnancy/birth condition may increase when breastfeeding during first few postpartum days. -comfort measures: empty bladder, apply warm blanket to abdomen, relaxation techniques and warm compresses can interfere with transmission and sensation of pain. Analgesics (ibuprofen) to relieve uterine cramping.

Uterine atony (boggy uterus)- LO 1

-(relaxation of the uterus) Results in a rapid, life threatening blood loss (postpartum hemorrhage). Treated by uterine massage, followed by drugs that promote uterine contraction. Sign that uterus is not contracted >Risk of hemorrhage is greatest within first hour of deliver.

Episiotomy LO 1

-A 1-to-2 inch surgical incision made in the muscular area between the vagina and anus (the perineum) -Midline - straight incision extending towards the anus. Heals more quickly and less painful -Mediolateral - incision extends downward and towards the side, 45 degree -After 24 hours of birth, the episiotomy edges should fuse/become closed -Nurse must assess for REEDA; watch for S/S of infection ICE PACKS!

Muscular and nervous system ASSESSMENT - LO 1

-Assess for diastasis recti abdominis- separation of rectus muscles -Assess for return of sensation, headache (can be associated with preeclampsia or post epidural/spinal headache), fatigue -May experience diminished lower body nerve sensation if received epidural. Delay ambulation until full sensation returns.

Cardiovascular nursing actions- LO 1

-Assess orthostatic hypotension- at risk during frist week pp. rise slowly to standing position, assist when ambulating during first few hours post birth, assist to sitting position if feeling dizzy/faint, ammonia ampule may be used if available -Assess excess blood loss (bradycardia may occur and considered normal). -Labs: CBC- hematocrit and hemoglobin assess EBL, hematocrit measures concentration of RBC in blood. Anemia not unusal during pp period. -DVTs assess & prevention; scd and frequently walk -Assess for postpartum chills- if experiencing with elevated temp, may indicate possible infection. -Educate: reduce risk of orthostatic hypotension, encourage frequent ambulation, don't cross legs, apply compression stockings for hx of blood clots.

Perineal nursing actions - LO 1

-Bottle with warm water to help with pain when urinating and keep it clean -Dermoplast -Large pad-wear them snugly to prevent rubbing and change them frequently (WASH HANDS FREQUENTLY) -Mesh underwear -Stool softener -Witch hazel- topical treatment -Ice pack- causes local vasoconstriction, decreases edema and provides anesthetic effect -Ibuprofen- treat perineal pain -Sitz bath- promotes circulation, healing and comfort -Lie on side- decreases pressure on perineum -Tighten gluteal muscles as she sits down and to relax muscles after seated- helps cushion perineum and increases comfort when assuming sitting position

GI nursing actions - LO 1

-Constipation...administer stool softeners as prescribed; encourage high-fiber diet (fruits, veggies, whole grains, and legumes) and ambulation: DRINK! -Avoid sitting for long periods, use witch hazel or topical anesthetics to reduce discomfort from hemorrhoids or sitz baths to promote circulation and reduce pain. -Need 500-1000 calories for breastfeeding moms. -Cultural food preference: ask if there are foods they prefer to eat based on culture, if not available, ask family members to bring homemade dishes.

GI system ASSESSMENT - LO 1

-Decreased muscle tone and motility. -Constipation- risk for constipation due to decreased GI motility from effects of progesterone, decreased physical activity, dehydration, and fluid loss from labor, fear of having bowel movement, etc -Hemorrhoids- develop hemorrhoids during pregnancy/birthing process. Slowly resolve but can be painful. HUNGRY and thirsty -Episiotomy - may result in painful defecation -Weight loss: have weight loss right away. Lose 11-12 pounds with delivery as result of delivery and blood loss, and 5-8 pounds with urine loss. Might be pre pregnancy weight or 3 pounds more than pre pregnancy weight around 6 months.

Lochia education - LO 1

-Estimated blood loss calculation: 1 g = 1 ml of lochia. -Save lochia if you are concerned to weigh it. -Oxytocin can stop bleeding for hemorrhage. -Assess: color, amount, and odor at same time uterus is assessed -Teach how to assess fundus and explain normal process of involution, how to massage uterus if boggy and notify nurse while in hospital and health care provider after discharge >Secondary hemorrhage often occurs after pt has been discharge. Women should understand normal progression and report abnormal bleeding to prevent serious complications. -Provide info of normal stages of lochia, explain flow of lochia can increase when getting up in morning or after sitting for prolonged periods of time due to vaginal pooling of lochia or excessive physical activity -Provide info of info for reducing risk of infection such as frequently changing peripad and use peri bottle

Fundus maternal assessment - LO 1

-Fundus: Should be midline and firmly contracted or soft (boggy) in tone. Fundus descends 1 finger breadth (1cm) per day in size >Boggy uterus indicates uterus is not contracting and places women at risk for excessive blood loss. >Treatment: massage fundus with palm of hand, give oxytocin, notify dr or midwife if uterus does not respond to massage and postpartum orders have been implemented, lack of response to fundal massage and oxytocin administration may indicate complications, measure distance b/w fundus and umbilicus with your fingers, determine position of uterus -Assess uterus for location, position, and tone of fundus -It is essential that the nurse assesses frequent fundal checks! (assess with VS, or more often if needed). Frequently assess uterine tone and placement allows for identification of potential complications (uterine atony) -Do not palpate the uterus (fundal check) without supporting the lower uterine segment! Prevents uterine inversion during fundal assessment or massage. -Main causes of post partum hemorrhage is boggy uterus. Massaging important. Along with vital signs, must check fundal. Have pt pee before fundal check so theres not a shift

Danger signs to report

-Heavy lochia saturating pad in 1 hour indicates secondary pp hemorrhage, return of bright red, heavy bleeding after lochia has diminished -Temperature greater than 100.4 F, chills, flu-like symptoms-indicates infection -Abdominal incision that is red, tender to touch, painful, separation of incisional edges- infection -Difficulty initiating urination, urinary frequency, or painful urination- cystitis -Increased vaginal bleeding with or without clots, or foul-smelling vaginal discharge- postpartum hemorrhage/ infection -Persistent pain or marked swelling at the perineal or episiotomy site- infection -Swelling or masses in the breasts, red streaks, shooting pain in breasts, cracked or bleeding nipples- mastitis -Swelling, warmth, tenderness, or painful areas in legs- venous thrombitis -Blurred vision, or persistent headaches not relieved by pain medication, fluid retention- preeclampsia -Overwhelming feelings of sadness, thoughts of harming self or infant; or inability to care for self or the infant- postpartum depression

cardiovascular system assessment- LO 1

-Immediate postpartum changes- cardiac output elevated for 24-48 hours and returns to prepregnancy levels within 10 days. -Average E B L 200-500 milliliters (vaginal); up to 1000 mL for c/s -Assessment of postpartum vital signs -Risk for thromboembolism r/t increase circulating clotting factors during pregnancy. Potential complication is pulmonary emboli.

Breast assessment/teaching- LO 1

-Non breastfeeding: >Assess: primary engorgement, tenderness, firmness, warmth, and/or enlargement, 24 hours=breasts should be soft and nontender; pp day 2= breasts slightly firm and nontender; pp day 3=firm and tender >Education: supportive bra, avoid expressing milk or stimulating breasts, treat engorgement by applying ice, don't express milk, and take analgesic for pain. Engorgement subsides 48-72 hours -Breastfeeding: Engorgement signs, mastitis, cracked, bleeding pain, plugged milk ducts, warm compresses help flow milk, expose nipples air after feed, feed infant frequently on demand or express milk if experiencing breast engorgement >Mastis: caused by bacterial entry through cracks in nipples and associated with milk stasis (buildup of milk), engorgement, long intervals b/w feedings, stress, and fatigue. ->Symptoms: fever, chills, malaise, flu like symptoms, unilateral breast pain and redness and tenderness ->Treatment: empty affected breast, antibiotic therapy, analgesic, rest adequate nutrition, and hydration

Vital signs Maternal assessment - LO 1

-VS (reflection of body's attempt to return to pre pregnant state) -Assess uterus - Taken every 15 in during first hour; every 30 min during second hour; once during third hour; then once every 4 hours X 24 hours; then every 8 hours or per shift until discharge (**varied protocols per facility) >Temp: 98.6-100.4F; mild temp elevations during first 24 hours postbirth is normal r/t muscular exertion, exhaustion, dehydration, or hormonal changes. >Pulse: 50-100 bpm >BP: consistent with baseline BP during first trimester >Respirations: 12-20 >Pain: should recognize and treat in a timely manner -Heart rate tachycardia is primary sign of hemorrhage then BP is second

Endocrine system - LO 1

-Nonbreastfeeding: >Estrogen begins to rise after first week pp. Nonlactating women- prolactin levels continue to decrease. >Menses begins 7-9 weeks post birth. >Ovulation occurs by fourth cycle. Non breastfeeding ovulation usually around 10 weeks pp. -Breastfeeding women- >prolactin levels increase, lactation suppresses menses bc hormonal changes >Return of meses depends on length and amount of breastfeeding >Ovulation suppressed longer for lactating woman than nonlactating women. Average ovulating return time is 17 weeks. -Both should be advised to use contraception, breast feeding not effective contraceptive method. -Diaphoresis: occurs first few weeks pp in response to decreased estrogen levels. Profuse sweating assists body in excreting increased fluid accumulated during pregnancy. >Assess for infection >Discuss comfort measures- wearing cotton nightwear. Report signs of infection

Discharge teaching and health promotion - LO 3

-Nutrition: Breastfeeding caloric intake 500-1000 cal per day and fluid intake of 2-3 L/day. Limit alcohol, wait 2-2.5 hours per drink before nursing. Use myplate and anemic should increase leafy green veggies, beans, red meat, poultry, rion fortified cereal, breads, pasta, and dried fruits. Prevent constipation, drink min of 10 glasses of fluids. -Permanent smoking cessation: reduce relapse of women who quit during pregnancy, teach dangers, never allow smoking around infant/child. Secondhand smoke associated with problems such as ear infections. Provide info about resources to stop smoking -Physical activity: moderate-intensity physical activity, such as brisk walking keeps heart and lungs healthy after pregnancy. Improves mood and maintain healthy weight. Should get at least 150 min (2.5 hours) moderate-intensity aerobic activity. Decreases constipation, promotes circulation and sense of well being. Encourage kegels. -Rest: teach importance of rest, problem solve to increase rest time, encourage to take meds as ordered (vitamins, iron, pain meds) -Family planning/ contraception: assess desire for future pregnancies, assess previous method of contraception, -Medication teaching: explain discharge meds, including dose, frequency, action, and side effects.

Discharge teaching - LO 3

-Plan discharge teaching over course of woman's postpartum stay rather than waiting for day of discharge -Incorporate checklist and pt education tool into hospital electronic health record systems and discharge education process will provide nurses with resource handout to use when providing evidence based care education.

Immune system - LO 1

-Postpartum vaccinations: rubella, Tdap >Rubella non immune should be immunized for rubella before discharge. Receive vaccinations such as Tdap, hep B, varicella, and influenza if needed pp -Rh-sensitization: Rh isoimmunization Rh- develop antibodies to Rh + blood from Rh + baby. Give Rhogam 300mcg IM or Rhophylac 300mcg IV or IM within 72 hours birth -Nursing actions: Negative blood type mother and positive blood type baby needs Rhogam after delivery. Blood crossing placenta and attacking fetal RBC, can cause hemolysis. Rh isoimmunization is preventable.

Breast assessment - LO 1

-Pregnancy prepares the breasts for the process of lactation- prolactin -Inspect/palpate for size, shape, tenderness, engorgement, firmness, warmth and color...regardless if breast or bottle feeding >Immediately after delivery- breast fullness normal; soft and nontender >Third day postpartum- primary breast engorgement, increase in vascular and lymphatic system of breasts that precedes initiation of milk production. Larger, firm, warm and tender. May feel throbbing pain. Subsides 24-48 hours. -Assess nipples for signs of irritation and nipple tissue breakdown >Cracked, blistered, or reddened. Skin breakdown associated with improper infant latch. Skin breakdown can be entry point for bacteria. -Assess for plugged milk ducts- associated with inadequate emptying of breasts and stasis of milk

Urinary system nursing actions - LO 1

-Promote hydration- drink 10 glasses of water per day; promote ambulation; administer analgesic before voiding as prescribed; utilize ice on perineum; sitz bath; privacy, -Encourage to void within 2-4 hours: early voiding decreases risk of cystitis and prevents bladder distention. -Assess for bladder distention, urinary retention may lead to cystitis. Catheterize if unable to spontaneously void and has over distended bladder postpartum. Can use peppermint oil so that vapors relax urinary sphincter. -Notify dr or midwife if pt reports frequency, urgency, burning on urination- indication of possible cystitis

Perineum assessment - LO 1

-Side-lying (Sim's) position with back facing the nurse -Must have adequate lighting -Lift buttock cheeks to visualize and assess lochia present and perineal area- May note hemorrhoids -Assess for REEDA (Redness, edema, ecchymosis, discharge/drainage, approximation) Assessed when fundus and lochia are checked in postdelivery -Expected findings: mild edema, minor ecchymosis, approximation of edges of episiotomy or laceration if visible, most lacerations are internal and not visible. Mild to moderate pain

Care of a Patient After a Cesarean Birth - LO 2

-Usual hospital stay is 3 days with full recovery. -Complications: prolonged labor, multiple interventions -Risks: hemorrhage, anemia, DVT, PE, paralytic ileus, infections, severe headache >Assess s/s of PE- dyspnea, tachypnea, chest tightness, shortness of breath, hypotension, and decreasing oxygen sat levels. s/s infection: serous or purulent drainage, erythema, fever, pain, and wound dehiscence >Endometritis s/s: fever, chills, uterine tenderness, foul smelling lochia >Pp hemorrhage: hypovolemic shock, disseminated intravascular coagulation, renal/hepatic failure, and possible need for emergency hysterectomy

C/S nursing actions - LO 2

-V/S, assess fundus/lochia, assess abdominal dressing, pain, side effects of intrathecal morphine, monitor level of sensation, seizures, spinal headache, breathing, i&o, skin to skin. SUNC-when healthy baby suddenly experiences resp and cardiac arrest. Decrease risk of SUNC during skin to skin contact. -Compression boots (SCDs) -Pain management -Surgical incision-bleeding, pain

Recovery from anesthesia LO 2

-VS -Ambulation -Deep breathe and cough (make sure pt has pillow to support her incision) -Ice chips/sips of water until bowel sounds are present -Foley catheter (removed around 12 hours) -Side effects anesthesia

First 24 hours after C/S birth - LO 2

-assess involutional changes and potential complications, assess pulmonary function, ileus. Medical orders (IV therapy, pain meds, stool softeners, progression of diet, remove foley, activity level). -Was the C/S planned? Or was it an emergent event? >Unplanned may experience guilt or sense of failure/disappointment. May ask questions about c/s birth and evens leading up to it.

Cystitis

-bladder inflammation/infection >Symptoms: frequency, urgency, pain/burning on urination, suprapbuic tenderness, hematuria, and malaise >Tx: antibiotic therapy, increased hydration, rest

Muscular and nervous system NURSING ACTION - LO 1

-promote rest/sleep -Relieve muscle soreness after delivery -Might need to put straight catheter if pt can't get up to go to bathroom. -Promote rest and sleep -Ice pack or heat to muscle soreness.

Oxytocin - LO 1

-stimulates upper segment of myometrium to contract rhythmically, which constricts spiral arteries and decreases blood flow through uterus. -Per ACOG-oxytocin may be initiated after delayed clamping of the umbilical cord, with delivery of the anterior shoulder, or with delivery of the placenta (provider choice) -First line treatment for postpartum hemorrhage-oxytocin >Rate 500mL/hr (10-40units/500 to 1000mL) >20units in 1L NS or LR bolus 1000mL/hr bolus 100mL/hr 30 minutes (equals 10units) maintenance of 125mL/hr next 3.5 hours (equals remaining 10units) >10units IM if no IV access >Have on hand: methylergonovine, misoprostol and carboprost -Give for: flaccid uterus and excess vaginal bleeding -Adverse reaction: coma, seizures, hypertension, hypotension, water intoxication -Duration and dosage based on assessment of fundal tone and amount of vaginal bleeding. -Assess: fundal position, tone, location, lochia color amount and odor, signs of water intoxication.

Stages and characteristics of lochia

1.) Lochia rubra - bloody with clots, moderate to scant; days 1-3 postpartum >Abnormal: large clots, heavy amount, saturates pad within 1 hour (sign of hemorrhage) excessively heavy, saturates pad in 15 min, foul odor (sign of infection), placental fragments) 2) Lochia serosa - pinkish brown, scant, increased flow during physical activity, fresh odor; 4-10 days postpartum >Abnormal: continuation of rubra stage after day 4, heavy amount; saturates pad within 1 hour (sign of possible hemorrhage), excessively heavy; saturates pad within 15 min, foul odor (sing of infection) 3) Lochia alba - white or yellow-white thick, scant; 10-14 days postpartum (present until 3 weeks postpartum, but may last until 6 weeks) >Abnormal: bright red bleeding, saturates pad within 1 hour (sign of possible late postpartum hemorrhage, foul odor (sign of infection)

Postpartum assessment- BUBBLE-HE(B) LO 1

B= breasts U= uterus B= bladder B= bowels L= lochia E= episiotomy L/H= legs (homan's sign-unreliable method) E= emotions B= bonding

Urinary system assessment- LO 1

Bladder -Voiding should occur within 2-4 hours after childbirth; encourage the patient to empty bladder every 4-6 hrs. -Transient stress incontinence associated with impaired pelvic muscle function involving urethra may occur in first 6 weeks pp. Factors: pregnancy, multiparity, perineal trauma, infant size, length of second stage labor, and pushing techniques increase pressure on pelvic floor. -Did the patient receive an epidural? Pt's that had epidural take longer to get up to go to the bathroom -Urinary output of at least 150ml/hr is necessary in avoiding urinary retention; urine output can reach up to 3000ml per day for the first 5 days. MEASURE URINE OUTPUT >May pour out a lot of urine at first- diuresis caused by decreased estrogen levels w/in 12 hours after birth and aids in elimination of excess tissue fluids.

Laceration assessment

First degree: vaginal mucosa torn Second degree: perineal muscles torn Third degree: anal sphincter torn Fourth degree: rectum torn

Follow up care - LO 3

Guidelines recommend women attend p follow up visit 4-6 weeks. Includes full assessment of physical, social, and psychological well-being with screening for pp depression, birth spacing recommendations, contraception, vaccination history and immunizations provided. Many women do not have pp follow up

Involution/subinvolution

Involution: describes the process whereby the uterus returns to the non pregnant state and placental site heals -Uterus weighs 1,000 g during immediate postpartal period; weighs 500 g after one week; eventually decreases to 100 g or less. Takes 6-8 weeks post delivery. Subinvolution: is the failure of the uterus to return to the non pregnant state. Causes include retained placental fragments, infection, and over distended uterus (from large baby). May lead to prolonged or excessive bleeding during postpartum period.

Lochia - LO 1

Lochia: (puerperal discharge of blood, mucus, and tissue) bloody discharge from uterus from uterus that contains RBC, sloughed off decidual tissue, epithelial cells, and bacteria. Prevents scarring of endometrial tissue. Undergoes changes that reflect healing stages of uterine placental site. Contractions constrict vessels around placental site and decrease blood loss Complication: metritis (infection of endometrial tissue Assessment: -Assess with VS or more often if indicated. Allows nurse to monitor blood loss and identify if bleeding is excessive, determine if clots are present and assess for signs of infection -Remove peripads to evaluate lochia at same time fundus is palpated

C/S 24 hours expected assessment - LO 2

Pain < 3; fundus firm midline or 1cm below; abdominal incision clean/dry/ intact without redness; voiding; passing gas; tolerate fluids/food; cares for newborn; vitals stable and lungs clear

POST BIRTH danger signs - LO 3

Pain in chest, Obstructed breathing or shortness of breath, Seizures, Thoughts of hurting yourself or your baby Bleeding/soaking through one pad/hour or blood clots or size of egg or bigger. Incision that is not healing. Red or swollen leg that is painful or warm to touch, Temperature of 100.4 or higher. Headache that does not get better even after taking med or bad headache with vision changes.