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Postpartum assessment & Care

Postpartum assessment

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.