Postpartum Assessment

POSTPARTUM Assessment of the fundal position and lochia changes Chapter 18 – pgs. 460-462 The return of the uterus to a nonpregnant state after birth is called involution. This process begins immediately after expulsion of the placenta with contraction of the uterine smooth muscle. Fundal massage – place hand at the lower segment of the uterus right over the pelvic bone, take dominant hand, starts at the umbilicus, and kind of feel down until you feel that top round ledge of the uterus. That’s the part you are going to depress down on to make sure that you have a firm fundus. We have to have a firm fundus. If we don’t, we have bleeding. Fundus The main thing that you want to look for is that the fundus is firm, and that it is going down so the involution processes happening. Usually we start looking for the fundus which is the top of the uterus at the umbilical line, if not lower. If the fundus is higher than the umbilical line. One of the things that you could think of is this the bladder full because the bladder will push the fundus up and out of the way. If the bladder is not full then you still need to start investigating why her involution process has stopped, and it has started going backwards where it's going up higher. Within 12 hours, the fundus can rise to approximately 1 cm above the umbilicus. By 24 hours after birth, the uterus is about the same size as it was at 20 weeks of gestation. Involution progresses rapidly during the next few days. The fundus descends 1 to 2 cm every 24 hours. By the sixth postpartum day, the fundus is normally located halfway between the umbilicus and the symphysis pubis. The uterus should not be palpable abdominally after 2 weeks and should have returned to its nonpregnant location by 6 weeks after birth Uterus Make sure the uterus is soft, it’s not soft and boggy. If it feels like a water balloon, that's soft and boggy, you want it to be firm, like a softball or baseball would be if it happens to be soft and bobby then you want to massage the area  Need to know where it is – if it is midline, it should be in the center of the women’s abdomen. If it’s into one side , you need to check the bladder  Before you do a fundal massage, ask when they last voided. If they haven’t void for the past hr, have them get up and void first and then do the fundal check.  At the end of the third stage of labor, the uterus is in the midline, approximately 2 cm below the level of the umbilicus, with the fundus resting on the sacral promontory. At this time, the uterus weighs approximately 1000 g Lochia Assess for the lochia, what color, and the odor of it is – if there is any clots. Looking at all this while massaging the uterus. You should be seeing lochia coming out from the vagina.  do we have extreme bleeding? Large saturation of the pad. When you push on the fundus, am I seeing a fountain or just little dribbles. We just want a little dribbles. Do we have clot or purulent? C-section have very little bleeding while vaginal delivers have more bleeding. For vaginal deliveries, you want to worry if you notice that your pt is soaking more than the size of a parry pad in less than 15 minutes Lochia – postbirth uterine discharge, initially is bright red (lochia rubra) and may contain small clots. For the first 2 hours after birth, the amount of uterine discharge should be about that of a heavy menstrual period. After that time, the lochial flow should steadily decrease.  Lochia rubra is bright red and consists mainly of blood and decidual and trophoblastic debris.         POSTPARTUM The flow pales, becoming pink or brown (lochia serosa) after 3 to 4 days. Lochia serosa consists of old blood, serum, leukocytes, and tissue debris. In most women, about 10 to 14 days after birth the drainage becomes yellow to white (lochia alba). Lochia alba consists of leukocytes, decidua, epithelial cells, mucus, serum, and bacteria. Lochia can persist up to 4 to 8 weeks after birth. If the woman receives an oxytocic medication, regardless of the route of administration, the flow of lochia is often scant until the effects of the medication wear off. The amount of lochia is usually less after a cesarean birth because the surgeon suctions the blood and fluids from the uterus or wipes the uterine lining before closing the incision. Flow of lochia usually increases with ambulation and breastfeeding. Lochia tends to pool in the vagina when the woman is lying in bed; the woman then can experience a gush of blood when she stands. This gush should not be confused with hemorrhage. Persistence of lochia rubra in the postpartum period suggests continued bleeding as a result of retained fragments of the placenta or membranes. It is not uncommon for women to experience a sudden, but brief, increase in bleeding 7 to 14 days after birth when sloughing of eschar over the placental site occurs. If this increase in bleeding does not subside within 1 to 2 hours, the woman needs to be evaluated for possible retained placental fragments. About 10% to 15% of women still have normal lochia serosa discharge at their 6-week postpartum examination. However, the continued flow of lochia serosa or lochia alba by 3 to 4 weeks after birth can indicate endometritis, particularly if the woman has fever, pain, or abdominal tenderness. Lochia should smell like normal menstrual flow; an offensive odor usually indicates infection. Not all postpartum vaginal bleeding is lochia; vaginal bleeding after birth can be caused by unrepaired vaginal or cervical lacerations. Postpartum Afterpains o The more babies a person has had, the more pain they will have. o Breastfeeding contracts the uterus, it will cause afterpains o Pharmacological management – Motrin (vaginal delivery) helps with swelling, which will probably have if they deliver vaginally. It will help with the pain. They can get it every 6 hours o Pharmacologic topical agents  Used on the perineum after delivering. It’s topical agents that has medications on it – lidocaine is the most common. It helps numb the pain they have from delivery o Periodic relaxation and vigorous contractions are more common in subsequent pregnancies and can cause uncomfortable cramping called afterpains (afterbirth pains), which typically resolve in 3 to 7 days. Afterpains are more noticeable after births in which the uterus was overdistended (e.g., macrosomic infant, multifetal gestation, polyhydramnios). Breastfeeding and exogenous oxytocic medication usually intensify afterpains because both stimulate uterine contractions Perineum o What assessments  First time that mom gets pregnant, that uterus grows to the size that it needs to be for the baby. And then when the baby's delivered it quickly shrinks back down. The second time a mom gets pregnant. That uterus gets bigger easier than it did the first time, and maybe a little bigger than it did the first time. And then when that baby goes out, that uterus has to work a little bit harder to shrink back down to its original size, but by the time you're having your fourth or fifth baby that uterus is really having to work to make itself get back down to that original size, therefore there's more after pains that they're having the more babies they have  Assess for swelling, hemorrhoids, any hematomas that might be forming in the perineum.  We want to make sure that the patient does not have hemorrhoids, but if they do, we want to make sure that we are helping them keep their stools soft, so they're not having to strain and irritate the hemorrhoids when they do have a bowel movement POSTPARTUM Many women do wind up with hemorrhoids after pushing, because we use the same muscles to push, as we do to have a bowel movement so that can often cause enlarged varicose veins also known as hemorrhoids in the rectal area.  We want to make sure that mom is increasing her fluids, and we want to offer stool softeners and get them eating more fiber in their diet to help if they do have any hemorrhoid  Most episiotomies and laceration repairs are visible only if the woman is lying on her side with her upper buttock raised or if she is placed in the lithotomy position. A good light source is essential for visualization of some repairs. Healing of an episiotomy or laceration is the same as any surgical incision. Signs of infection (pain, redness, warmth, swelling, or discharge) or lack of approximation (separation of the edges of the incision) can occur. Initial healing occurs within 2 to 3 weeks, but 4 to 6 months can be required for the repair to heal completely  Sometimes will have laceration or episiotomy  Make sure you don’t see hematoma – blood vessels will tear during delivery Meds  Motrin or Tylenol for their pain motor. Motrin also helps with the swelling. If the perineum is swollen, motrin will help with the cramping of the uterus and the swelling of the perineum.  Opioids  Narco or cyconin  We try hard not to give opiods. So, if they've got Tylenol or Motrin ordered and it's not helping with the pain, then we would contact the physician to try and get them something stronger.  Obviously if the patient has had a C section. Then we use stronger medications sometimes for the first 24 hours, you'll see toradol or morphine ordered for your C section mom.  After that we changed them over to PO meds, and that mom might be getting the Norco and Bicoden and eventually transition to Motrin and Tylenol Nonpharmacologic measures  We want to give them ice packs to put on their bottoms so that we can that swelling down and Motrin  Sitz baths, but sitz baths are not used as often as they used to be  o o POSTPARTUM What’s happening Chapter 18 – ps. g464-465  V/S changes o V/S – Increased bp may be caused by pain, decrease in bp may indicate dehydration or hypovolemia from bleeding  We also have to remember that this patient had tons of excess blood flowing through their body, and now their body has to start getting rid of that so we may see a fluctuation in vital signs because of that  Mom’s temperature will usually elevate a little when milk comes in but it’s not until 48 to 72 hrs. before that, mom should be below 100.4. we don’t worry about infection unless it’s above 100.4  BP will usually stabilize, and it can lower a little. CO increases between 30 to 50% when they got pregnant. Their CO needs to go back to normal so as they start to diaphoresis and diuresis and get rid of that excess fluid volume, their BP may lower a little bit  There is a transient increase in blood pressure of approximately 5% during the first few days after birth (Isley & Katz, 2017). It can take weeks or months for pulse and blood pressure to return to prepregnancy levels. Increase in blood pressure greater than 140/90 when measured on two or more occasions at least 6 hours apart can indicate preeclampsia.  Respiratory function rapidly returns to nonpregnant levels after birth. After the uterus is emptied, the diaphragm descends, the normal cardiac axis is restored, and the point of maximal impulse and the electrocardiogram are normalized.  Low grade fever is not uncommon during the first 24 hours after birth. However, temperature elevation of 38° C (100.4° F) or higher during the first 10 days postpartum can indicate infection and should be evaluated  As many as 50% of women experience shivering episodes during the first few minutes up to the first hour after birth. The exact cause is unknown, and usually no treatment is needed; if the shivering is related to the effects of anesthesia, pharmacologic treatment may be needed o Orthostatic hypotension – After birth, rapid decrease in intraabdominal pressure resulting in dilation of blood vessels supplying the viscera. Results in engorgement of abdominal blood vessels and rapid fall in BP can cause dizziness & light headed  rapid decrease in the intra abdominal pressure, and that results in dilation of blood vessels that have been supplying the viscera. And this can result in engorgement of abdominal blood vessels, and that rapid fall in that blood pressure, that can cause dizziness and lightheadedness  it goes back to all of that hyperkalemia that was going on with the moms body they had all of this increased blood and fluid that was flowing through their body, and now suddenly after delivery it's all starting to plummet o Pulse – Brady, reflects the large amount of blood that returns to the central circulation after delivery of the placenta.  Mom was producing all of that extra blood to supply blood to that placenta but now that the placenta is gone, the body is still shortly after trying to supply that placenta.  And now that increased blood flow may wind up, giving the mom a little bit of blood produce bradycardia  Pulse rate should stay normal. If pulse rate starts to elevate and BP starts to drop. You need to be concerned about hemorrhage or hypovolemic shock o Tachy with pain, anxiety, fatigue, dehydration, hypovolemia, anemia or infection o Normal respirations POSTPARTUM they might have had a little bit faster respirations because of pressure being put on the diaphragm from the baby but now that all of that pressure is gone and the uterus isn't up so high, one's respiration should return to normal  RR may stay stable. It might be a little less since their diaphragm does not have so much pressure from the baby.  When birth occurs, there is an immediate decrease in intraabdominal pressure, which allows for greater excursion of the diaphragm. With decreased pressure on the diaphragm and reduced pulmonary blood flow, chest wall compliance increases. Rib cage elasticity can take months to return to a prepregnancy state. The costal angle that was increased during pregnancy may not completely return to the prepregnancy level. The decline in progesterone that occurs with loss of the placenta causes PaCO2 levels to rise o Slight increase in temp within first 24 hours or so  You might see in the first 24 to 48, hours a slight increase in temperature  If you see temperature above 100.4, it is an indicator of a sign of infection Assess signs and symptoms Note the patient’s history & meds o Does pt have hx of postpartum hemorrhage since it can happen again? Hypervolemia after birth o Protective mechanism o Hypervolemia is caused immediately after birth because the body is used to the increased production of blood for the placenta and the body has to then work to get this overload out What is the H/H before and after delivery? o Why does this matter?  H/H is the best indicator as to how the blood loss affected the body  Baseline and after delivery  What other lab values should we watch? o WBC – greatest indicator of infection . when pregnant woman deliver, their body is under stress. At the end of pregnancy and right after delivery, their WBC is a little bit higher  Look at the greater picture – do they have a temperature of 101.4 or do they have tachycardia  Normal leukocytosis of pregnancy ranges from 5,000 to 15,000/mm3. During and after labor the white blood cell count may rise to 30,000/mm3. Leukocytosis, coupled with the increase in erythrocyte sedimentation rate that normally occurs, can obscure the diagnosis of acute infection o Hematocrit and hemoglobin  In women with an average blood loss during birth, the hematocrit level drops moderately for 3 to 4 days, then begins to increase, and reaches nonpregnant levels by 8 weeks postpartum. A postpartum hematocrit can be lower than normal if the blood loss was increased or if the hypervolemia of pregnancy was less than normal. o Coagulation Factors  Clotting factors and fibrinogen are normally increased during pregnancy and remain elevated in the immediate puerperium. When combined with vessel damage and immobility, this hypercoagulable state causes an increased risk for venous thromboembolism, especially after a cesarean birth. Fibrinolytic activity also increases during the first few days after birth. Factors I, II, VIII, IX, and X decrease to nonpregnant levels within a few days. Fibrin split products, probably released from the placental site, can be found in maternal blood.       POSTPARTUM Postpartum assessment Cesarean section Chapter 17 – pgs. 451-452 You want to be doing the same assessment as you would be doing that vaginal patient     Assessments? o Incision  you need to make sure that the incision is well approximated, you need to be counting your suture or your staples so that you know that they're all there and intact and not missing you want to look for any redness and swelling, any drainage is that hot to the touch  it is well approximated, it is hot and warm to touch, how many sutures or staples are there and if it’s the same amount after reassessing.  Tenderness. Make sure it is staying approximate since C-section can open up o Fundus/lochia  We’re looking at the fundal height. We’re looking if it is foggy, you're still doing a fundal check so pushing on that uterus to see if it's firmer boggy, just because the patient has had a C section does not mean that you do not do a regular fundal assessment  Do the same thing as vaginal delivery o GI  You want to know that their GI system should start to return to normal within about 12 to 24 hours, it will still be slowed after surgery, and the fact that they hadn't had anything to eat or drink, but it should return to normal o GU  Pt probably had a Foley. If they still have the Foley, we need to be monitoring the pt’s output. If the foley is out, we need to be monitoring their output to make sure that they’re able to void after the Foley comes out  If the patient had a Foley, that we're watching for signs and symptoms of infections such as a UTI. o Postpartum diuresis  Remember that when this patient is getting rid of all of this excess Diaphoresis – sweating fluid they should be voiding. They should be getting all of this fluid Diuresis – increase out and you'll see that through diuresis and diaphoresis. The body’s urine output way of compensating Interventions? o We want to get up and moving, a mom who had a C-section has a higher risk of getting a blood clot. We want to make sure that we're keeping this patient's pain under control, so that she can get up and walk and be comfortable doing it. Common Meds? o Toradol is the most common given medication through their IV. After that, they will usually have an order for Norco for PO and Motrin. We recommend alternating those two medications since both are every 6 hours so they can take a Norco or Vicotin then 3 hours later, they can have a Motrin and then 3 hours later. We suggest for them to keep their medications, it is easier to keep pain under control that it is to get out of control pain under control Complications of meds? o We want to make sure that if the mom is on is taking pain medications that she knows how those pain medications are going to affect her. Complications of the meds could be that if we're giving this mom what she could be extremely sleepy o o POSTPARTUM You also want to let the mom know that some medications that she takes may pass through breast milk. And if it makes her sleepy. It can also make the baby sleepy. Don’t leave the pt unattended when giving Nocro. Find out if the pt had the medication before and how it affect their system. We need to make sure that the mom will be able to care for the baby. Do not leave her alone holding the baby in the bed Safety Alert When holding her baby or breastfeeding, a woman may become drowsy and even fall asleep because of the sedation that occurs with the use of analgesics. It is important that someone be with her during these times to prevent newborn injury. Postpartum assessment Vaginal Delivery Chapter 18 – pgs. 460-461        Fundus/lochia – see above o We also need to be doing our fundal checks, looking at lochia, how much bleeding is there in the pancreas if its nice and firm o Do we have a boggy uterus o Do we need to some type of massaging or interventions GU o A vaginal mom probably did not have Foley unless she had an epidural she may had a Foley. o Watch urinary output for these mom as well because they have so much swelling in their perineal area so it can affect the patient’s ability to be able to void if the urethral opening is swollen as well o When a pt delivery vaginally, they can have urethral tears so it can cause some pain with urination, and they have a difficult time voiding as well Perineum – episiotomy/laceration o We are looking for swelling, redness, any type of tears or lacerations, we want to make sure that we are giving an episiotomy or laceration care if the patient had an episiotomy or laceration o We can take their peri pad, we can put an ice pack in with their peri pack with some moist tuck pads over that ice pack and then use the Epiphone which is a spray and a foam to put right on top it. When it comes in contact with the patient’s perineum skin. It has a lidocaine in it that helps numb the area so it can help with the pain. Hemorrhoids o If they have hemorrhoids, you want to make sure we are giving them medication on how to keep their stools soft and moving easily so they’re not straining the assessments Assessment? o Assess their pain level o We want to be assessing their swelling, we want to make sure eveyrthing that is going on with them since they’re delivered Interventions? o We don’t want them to be laying in bed. We want to help them with their peri pads and their changing. Common meds? o Moltrin and Tylenol. Some mom’s need a bit more with some Norco or bicodaine but it’s just not done often POSTPARTUM Focused physical and psychosocial assessment Physical Assessment Chapter 18 – pgs. 462-463 • Cardiac volume – vital signs Legs – s/s of blood clots PP blues – not able to care for self or infant • Changes in blood volume after birth depend on several factors, such as KNOW THE DIFFERENCE blood loss during birth and the amount of extravascular water (physiologic BETWEEN PP BLUES AND REGULAR DEPRESSION edema) mobilized and excreted. Pregnancy-induced hypervolemia (an increase in blood volume to 40% to 45% above nonpregnancy levels) allows most women to tolerate considerable blood loss during birth. The average blood loss for a vaginal birth of a single fetus ranges from 300 to 500 mL (10% of blood volume). The typical blood loss for women who give birth by cesarean is 500 to 1000 mL (15% to 30% of blood volume). During the first few days after birth, the plasma volume decreases further as a result of diuresis • Maternal physiologic changes in the puerperium enable the woman to cope with the blood loss that normally occurs during birth by increasing her circulating blood volume. • • Mention bonding – skin to skin These changes are: • (1) elimination of uteroplacental circulation that reduces the size of the maternal vascular bed by 10% to 15%; • (2) loss of placental endocrine function that removes the stimulus for vasodilation; and • (3) mobilization of extravascular water stored during pregnancy. By the third postpartum day, the plasma volume has been replenished as extravascular fluid returns to the intravascular space • The body rids itself of the excess plasma volume needed during pregnancy by diuresis and diaphoresis. . • Diuresis (increased excretion of urine) is facilitated by a decline in the adrenal hormone aldosterone and a decrease in oxytocin. A urinary output of up to 3000 mL/day may occur, especially on days 2 through 5 postpartum • Diaphoresis (profuse perspiration) also rids the body of excess fluid. It can be uncomfortable and unsettling for the mother who is not prepared for it. Explanations of the cause and provision of comfort measures such as showers and dry clothing are generally sufficient. Breast • You want to be asking them how their breasts are doing. But if a mom tells you that she's having pain in her breast you need to inspect the breast as well. Sometimes it's as simple as important, or that the baby is not latching right and that's where the pain is coming from, but we need to make sure of where it is • Promptly after birth, a decrease occurs in the concentrations of hormones (i.e., estrogen, progesterone, hCG, prolactin, cortisol, and insulin) that stimulated breast development during pregnancy. The time required for these hormones to return to prepregnancy levels is determined in part by whether or not the mother breastfeeds her infant. • Breastfeeding mothers • • • The breasts can feel warm, firm, and somewhat tender. Bluish white milk with a skim-milk appearance (true milk) can be expressed from the nipples. As milk glands and milk ducts fill with milk, breast tissue can feel somewhat nodular or lumpy. Unlike the lumps associated with fibrocystic breast changes or cancer (which can be palpated consistently in the same location), the nodularity associated with milk production tends to shift in position. Some women experience engorgement at this time due to an increase in blood and lymphatic fluid as milk production increases. • Engorged breasts are hard and uncomfortable; the fullness of the nipple tissue can make it difficult for the infant to latch on and feed. With frequent breastfeeding and proper care, engorgement is a temporary condition that typically lasts only 24 to 48 hours Nonbreastfeeding mothers • • • • • • The breasts generally feel nodular in contrast to the granular feel of breasts in nonpregnant women. The nodularity is bilateral and diffuse. Prolactin levels drop rapidly. Colostrum is present for the first few days after birth. Palpation of the breasts on the second or third day as milk production begins can reveal tissue tenderness in some women. On the third or fourth postpartum day, engorgement can occur. The breasts are distended (swollen), firm, tender, and warm to the touch. Breast distention is caused primarily by the temporary congestion of veins and lymphatics rather than by an accumulation of milk. Milk is present but should not be expressed. Axillary breast tissue (the tail of Spence) and any accessory breast or nipple tissue along the milk line can be involved. Engorgement resolves spontaneously, and discomfort decreases usually within 24 to 36 hours. A breast binder or well-fitted supportive bra, ice packs, fresh cabbage leaves, and/or mild analgesics may be used to relieve discomfort. Nipple stimulation is avoided. If suckling or milk expression is never begun (or is discontinued), lactation ceases within a few days to 1 week. Pain • • POSTPARTUM During the first 24 hours after birth, there is little if any change in the breast tissue. Colostrum, or early milk, a clear yellow fluid, can be expressed from the breasts. The breasts gradually become fuller and heavier as the colostrum transitions to mature milk by about 72 to 96 hours after birth; this is often referred to as the “milk coming in,” or lactogenesis II. We want to assess the mom’s perinatal pain, incisional pain. GI/GU • Most new mothers are very hungry after full recovery from analgesia, anesthesia, and fatigue. Requests for extra portions of food and frequent snacks are common. • A spontaneous bowel evacuation may not occur for 2 to 3 days after birth. This delay can be explained by slowed peristalsis related to decreased muscle tone in the intestines during labor and the immediate postpartum period, prelabor diarrhea, lack of food, or dehydration. The mother often anticipates discomfort during the bowel movement because of perineal tenderness as a result of an episiotomy, lacerations, or hemorrhoids and resists the urge to defecate. Regular bowel habits should be reestablished when bowel tone returns. • Third- and fourth-degree perineal lacerations that involve the anal sphincter are associated with an increased risk for postpartum anal incontinence. Women with this problem are more often incontinent POSTPARTUM of flatus than of stool. If anal incontinence lasts more than 6 months, studies should be conducted to determine the specific cause and appropriate treatment • • • • Kidney function returns to normal by 8 weeks after birth. About 6 weeks are required for the pregnancyinduced hypotonia and dilation of the ureters and renal pelvis to return to the nonpregnant state in a small percentage of women, dilation of the urinary tract can persist for 3 months or longer, increasing the risk for developing a urinary tract infection I&O • We want to make sure that they're avoiding and stalling and eating the way that they're supposed to be. We want to watch there is a lot of fluid into mothers that labor or have C sections. We need to make sure that we're getting that fluid out • So we're watching for swelling, when we're looking at the extremities we're looking for swelling we're looking for pain Extremities • In the first 1 to 2 days after childbirth, many women experience muscle fatigue and aches, particularly of the shoulders, neck, and arms, because of exertion during labor. Warmth and gentle massage increase circulation to the area and provide comfort and relaxation. • During the first few days, levels of the hormone relaxing gradually subside, and ligaments and cartilage of the pelvis begin to return to their prepregnancy positions. These changes can cause hip and joint pain that interferes with ambulation and exercise. The mother should be told that the discomfort is temporary and does not indicate a medical problem. Good body mechanics and correct posture are important during this time to help prevent low back pain and injury to the joints • The legs are examined for varicosities and signs or symptoms of thrombophlebitis. Indications of thrombophlebitis include localized areas of redness, heat, edema, and tenderness. Pedal pulses may be obstructed by a thrombus and should be palpated with each assessment Risk factors? • Does she have something that predisposes her to increased bleeding or predisposes her to blood clots, we need to be paying attention to those risk factors with that patient. You also want to make sure that you're talking to your patient about bonding with their baby skin to skin, holding the baby doing things for the baby POSTPARTUM Psychosocial Assessment Chapter 20 – pg. 493 • • • • Postpartum Blues • The “pink” period surrounding the first day or two after birth, characterized by heightened joy and feelings of well-being, is often followed by a “blue” period. Many women of all ethnic and racial groups experience the postpartum blues or “baby blues.” During the blues, women are emotionally labile and often cry easily for no apparent reason. Timeframe • This lability seems to peak around the fifth day and subside by the tenth day. • The condition begins in the first week, peaks around day 5, and ends within 2 weeks. If it lasts beyond 2 weeks, it may be a more serious condition Why? • whatever the cause, the early postpartum period appears to be one of emotional and physical vulnerability for new mothers, who are often psychologically overwhelmed by the reality of parental responsibilities. • Mothers feel deprived of the supportive care they received from family members and friends during pregnancy. Some mothers regret the loss of the mother–unborn child relationship and mourn its passing. Still others experience a let-down feeling when labor and birth are complete. • The majority of women experience fatigue after childbirth, which is compounded by the around-theclock demands of the new baby. Postpartum fatigue increases the risk for postpartum depressive symptoms and can have a negative effect on maternal role attainment. • During the postpartum period, it is common for women to experience disrupted sleep. While breastfeeding mothers may be awake more frequently during the night to breastfeed compared with mothers who formula-feed, there is evidence to suggest that breastfeeding, which enhances maternal role attainment, can also help improve maternal sleep • May be a result of the emotional letdown that occurs after birth, postpartum discomforts, sleep deprivation, anxiety about her ability to care for the infant, and body image concern Symptoms: • let-down feeling, restlessness, fatigue, insomnia, headache, anxiety, sadness, and anger. • The symptoms are usually unrelated to events, and the condition does not seriously affect the mother’s ability to care for the infant. Nurses should prepare women and their family members for the occurrence of postpartum blues symptoms, let them know it is normal, and offer emotional support and encouragement POSTPARTUM Postpartum depression Chapter 21 – pgs. 518-527 Symptoms of PPD can range from mild to severe, with women having good days and bad days. Fathers can also experience PPD. Screening for PPD should be performed with both mothers and fathers. PPD can go undetected because new parents generally do not voluntarily admit to this kind of emotional distress out of embarrassment, guilt, or fear. Nurses need to include teaching about how to differentiate symptoms of the “blues” and PPD and urge parents to report depressive symptoms promptly if they occur. • Edinburgh Postnatal Depression Screen • screening that is done nationwide in postpartum units to be filled out from the mom and postpartum before she’s discharged from the hospital so that we can see if there’s a high risk for her to suffer from depression The cause of PPD can be biologic, psychologic, situational, or multifactorial. The change from the high levels of estrogen and progesterone at the end of pregnancy to the much lower levels of both hormones that are present after birth are important etiologic factors in the development of PPD. While all women experience these hormonal changes, there are some who are more sensitive to the mood-destabilizing effects of withdrawal from the pregnancy hormones and are therefore at risk for PPD. Poor nutrition may also be a contributing factor. Folate and vitamin B12 are needed for the synthesis of serotonin and other neurotransmitters. Marginal or low folate also increases the likelihood of a poor response to antidepressant medication as well as the potential for relapse in people who initially responded well to pharmacologic therapy. Women at greatest risk for PPD are those with a history of anxiety or depression and especially those who had a previous episode of major depressive disorder in the past, including during or after pregnancy. Other risk factors include younger age, unintended pregnancy, personal history of severe premenstrual dysphoria, family history of mood disorder, unmarried status, marital discord, lack of social support, socioeconomic deprivation, lower education, substance abuse, low self-esteem, and stressful life events. Women facing multiple or severe psychosocial problems or chronic interpersonal difficulties are at increased risk for PPD. Complications of pregnancy and birth increase the risk for PPD. Having a preterm, low–birth weight, and ill neonate is associated with higher rates of PPD. Women who are victims of intimate partner violence are at increased risk for PPD. Cultural practices can positively or negatively affect the development of PPD. Signs and Symptoms Postpartum depression, also known as PPD without psychotic features, is an intense and pervasive sadness with severe and labile mood swings. It is more serious and persistent than postpartum blues, lasting more than 2 weeks. Intense fears, anger, anxiety, and despondency that persist past the baby's first few weeks are not a normal part of postpartum blues. These symptoms rarely disappear without outside help. Most of these mothers seek help only after reaching a “crisis point.” The symptoms of postpartum major depression are very similar to those of adult depression except that the mother's ruminations of guilt and inadequacy feed her worries about being an incompetent and inadequate parent. In PPD, there can be loss of appetite or odd food cravings (often sweet desserts) and binges with abnormal appetite and weight gain. Sleep disturbance is common. Sleep deprivation is a factor in the development of PPD, and it can worsen the symptoms A distinguishing feature of PPD is irritability. These episodes of irritability can flare up with little provocation, and they sometimes escalate to violent outbursts or dissolve into uncontrollable sobbing. Many of these outbursts are directed against significant others. Women with postpartum major depressive episodes often have severe anxiety, panic attacks, and spontaneous crying long after the usual duration of baby blues. POSTPARTUM Feelings of detachment toward the newborn or not feeling love for the newborn are common symptoms of PPD. Women feel guilt and shame for having these feelings and are not likely to verbalize or discuss this with anyone. Many women feel especially guilty about having depressive feelings at a time when they believe they should be happy. They can be reluctant to discuss their symptoms or their negative feelings toward the infant. A woman with PPD may have obsessive thoughts about harming the infant, and this can be very frightening to her. Often she does not share these thoughts because of embarrassment; when she does, other family members become very frightened. On the other hand, some women feel very emotionally attached and connected to their infants; this can prevent them from experiencing total despair Medical Management The natural course is one of gradual improvement over the 6 months after birth. Treatment options for PPD include psychotherapy and antidepressant medication. Antidepressants are the most commonly used treatment; one explanation for this is that primary care providers can prescribe these medications and monitor the woman's progress. In some communities, access to mental health care providers is limited and primary care providers treat women with PPD. Psychotherapy without the use of medication can be effective for mild cases of PPD. It is often used in combination with antidepressants for moderate to severe cases. Psychotherapy methods include general counseling (listening visits), interpersonal psychotherapy (IPT), cognitive-behavioral therapy (CBT), and psychodynamic therapy For more severe PPD, antidepressant medication is combined with some form of psychotherapy. Often, an SSRI is prescribed initially and if symptoms improve during a 6-week trial period, the medication is continued for at least 6 months to prevent relapse. If response to the medication is less than optimal, another SSRI may be prescribed instead Sleep deprivation must be resolved; 4 to 5 hours of uninterrupted sleep for several days may help the woman to begin the road to recovery from PPD. Planning with the woman and her family to protect her sleep as much as possible is essential to the plan of care POSTPARTUM Postpartum Psychosis The most severe of the perinatal mood disorders, postpartum psychosis, also known as postpartum depression with psychotic features, occurs in 1 to 2 per 1000 births during the first month, although it usually manifests within the first 2 weeks postpartum Because the recurrence rate of postpartum psychosis is 50%, women with a history of postpartum psychosis are at significant risk. Other risk factors include bipolar disorder, family history of bipolar disorder or postpartum psychosis, and recent discontinuation of lithium or other mood stabilizers. Primiparous women are more likely to suffer from postpartum psychosis, especially if they experienced obstetric complications Postpartum psychosis can be due to major depression. However, it is most commonly associated with bipolar disorder (or manic-depressive disorder) and presents with symptoms of mania, depression, or both Postpartum psychosis is defined by the presence of abnormally elevated energy levels, cognition, and mood; and one or more depressive episodes. The elevated moods are generally referred to as mania. Clinical manifestations of a manic episode include at least three of the following: grandiosity, decreased need for sleep, pressure speech, flight of ideas, distractibility, psychomotor agitation, and excessive involvement in pleasurable activities without regard for negative consequences. Individuals who experience manic episodes also commonly experience depressive episodes or symptoms of mixed episodes in which features of both mania and depression are present at the same time. These episodes are usually separated by periods of normal mood, but in some individuals, depression and mania rapidly alternate. These rapid changes in mood are known as rapid cycling. In general, postpartum psychosis is characterized by rapid onset of bizarre behavior, auditory or visual hallucinations, paranoid or grandiose delusions, elements of delirium or disorientation, and extreme deficits in judgment accompanied by high levels of impulsivity that can contribute to increased risk for suicide or infanticide (O'Hara & Wisner, 2014). Initially the woman may complain of fatigue, insomnia, and restlessness and can have episodes of tearfulness and emotional lability. Later, suspiciousness, confusion, incoherence, irrational statements, and obsessive concerns about the baby's health and welfare can be present. Hallucinations and delusions are common. Auditory hallucinations that command the mother to kill the infant can occur in severe cases. When delusions are present, they are often related to the infant. The mother may think the infant is possessed by the devil, has special powers, or is destined for a terrible fate. Grossly disorganized behavior can be manifested as a disinterest in the infant or an inability to provide care. Some women will insist that something is wrong with the baby or accuse nurses or family members of hurting or poisoning their child. Medical Management Women with postpartum psychosis usually need inpatient psychiatric care. Antipsychotics, mood stabilizers, and benzodiazepines are the treatments of choice. Other psychotropic medications such as antidepressants may be used based on the underlying diagnosis (e.g., bipolar mania, bipolar depression). ECT, especially when bilaterally administered, has also been shown to be highly effective in the treatment of postpartum psychosis. It is usually advantageous for the mother to have contact with her baby if she so desires, but visits must be closely supervised. Psychotherapy is indicated after the period of acute psychosis has passed. POSTPARTUM Teach for self-care Teach the mom about normal changes during the postpartum period: • Progressive descent of fundus, changes in lochia • Be aware of postpartum fatigue and try to obtain extra rest • Also be aware that they are going to be extremely tired and we need to try and teach them that they're going to need extra rest. • Nutritional needs: Adequate hydration, dietary measures if anemic, nutritional needs for breastfeeding • Increase calories (300/day); Calcium 1200mg per day, increase water intake • • We don’t want mother who is breastfeeding to be dieting because if mom is dieting the baby is dieting. They need to have adequate hydration if they’re breastfeeding especially because the body is going to give the baby what the baby needs, and the mom is going to suffer from it. • If the mom is not well hydrated, she’s not going to produce milk like she needs to which hinders her breastfeeding as well Mother needs to be aware of action of prescribed medications and potential side effects • • We need to make sure that if mom's anemic we're giving her information on what food she can be taking to help increase her iron levels in her system, as well as the medications that the doctor would like for them to be able to take. And then we need to make sure that if mom is breastfeeding that we’re explaining to her that she needs to have an increase in her caloric intake so that she and the baby are getting healthy amounts of nutrients from breastfeeding Teach about comfort measures, activity, methods to prevent fatigue, coping skills POSTPARTUM Postpartum hemorrhage Chapter 21 – pgs. 506-508 Postpartum hemorrhage is a life-threatening event that can occur with little warning and is often not recognized until the mother has profound symptoms. Definitions of PPH in the literature are varied. PPH is often defined as the loss of 500 mL or more of blood after vaginal birth and 1000 mL or more after cesarean birth, although normal blood loss for some women approaches these amounts. PPH may be defined as a 10% change in hematocrit from the time of admission to the birthing facility for labor until postpartum; or it may be defined by the need for erythrocyte transfusion. Postpartum hemorrhage is classified as early or late with respect to the birth. Early, acute, or primary PPH occurs within 24 hours of the birth. Late or secondary PPH occurs more than 24 hours but less than 6 weeks after the birth. • What to monitor? • Vs – increased temp, foul When excessive bleeding is observed, it is important to note the color and smelling lochia consistency of the blood as well as the stage of labor. From birth of the Temperature greater than infant until separation of the placenta, the character and quantity of 100.4 on 2 occasions 6 blood expelled from the vagina can suggest excessive bleeding. For hours apart, start thinking puerperal infection example, dark red blood is likely of venous origin, perhaps from varices or superficial lacerations of the birth canal. Bright blood is arterial and can indicate deep lacerations of the cervix. Spurts of blood with clots can indicate partial placental separation. Failure of blood to clot or remain clotted indicates a pathologic condition or coagulopathy such as disseminated intravascular coagulation (DIC) Excessive bleeding can occur during the period from the separation of the placenta to its expulsion or removal. This can result from incomplete placental separation, undue manipulation of the fundus, or excessive traction on the cord. After the placenta has been expelled or removed, persistent or excessive blood loss usually is the result of uterine atony or prolapse of the uterus into the vagina. Late PPH can be the result of subinvolution of the uterus, endometritis, or retained placental fragments • Priority Nursing assessments > see picture • What interventions to do first Clinical Manifestations  A uterine fundus that is difficult to locate .  A soft or “boggy” feel when the fundus is located .  A uterus that becomes firm as it is massaged but loses its tone when massage is stopped .  A fundus that is located above the expected level .  Excessive lochia, especially if it is bright red .  E i l t ll d ith ith • Whenever blood loss appears to be excessive, the first step is to evaluate the contractility of the uterus. If the uterus is hypotonic or boggy, management is directed toward increasing contractility and minimizing blood loss. • If the uterus is firmly contracted and bleeding continues, the source of bleeding still must be identified and treated. Assessment may include visual or manual inspection of the perineum, the vagina, the uterus, the cervix, or the rectum, as well as laboratory studies (e.g., hemoglobin, hematocrit, coagulation studies, platelet count). Treatment depends on the source of the bleeding. • Oxygen can be given by nonrebreather face mask to enhance oxygen delivery to the cells. An indwelling urinary catheter is usually inserted to monitor urine output as a measure of intravascular volume. Laboratory studies usually include a complete blood count with platelet count, fibrinogen, fibrin split products, prothrombin time, and partial thromboplastin time. Blood type and antibody screen are done if not previously performed POSTPARTUM • Early Causes: • Early usually occurs w/in first hour to 24 hours after birth and caused by uterine atony • • • Uterine Atony • The greatest risk for early postpartum hemorrhage is during the first hour after birth. During this time, large venous areas are exposed after the placenta separates from the uterine wall. The corpus or body of the uterus is essentially a basket-weave of strong, interlacing smooth muscle bundles through which many large maternal blood vessels pass • Bleeding is controlled by the contraction of smooth muscle in the uterus. If the uterus is flaccid after detachment of all or part of the placenta, brisk venous bleeding occurs, and normal coagulation of the open vasculature is impaired and continues until the uterine muscle is contracted. This marked hypotonia of the uterus is called uterine atony. • Uterine atony is the leading cause of early PPH. It is associated with high parity, polyhydramnios, fetal macrosomia, obesity, and multiple gestation. In such conditions, the uterus is “overstretched” and contracts poorly after birth. Other causes of atony include traumatic birth, use of halogenated anesthetic (e.g., halothane), magnesium sulfate, rapid or prolonged labor, chorioamnionitis, use of oxytocin for labor induction or augmentation, and uterine atony in a previous pregnancy Nonpharmacologic – massage, empty bladder • If the uterus is not firmly contracted, despite preventive measures, the first intervention is to massage the fundus until it is firm and to express clots that may have accumulated in the uterus. One hand is placed just above the symphysis pubis to support the lower uterine segment while the other hand but firmly massages the fundus in a circular motion • Clots that may have accumulated in the uterine cavity interfere with the ability of the uterus to contract effectively. They are expressed by applying firm but gentle pressure on the fundus in the direction of the vagina. It is critical that the uterus is contracted firmly before attempting to express clots. Pushing on a uterus that is not contracted could invert the uterus and cause massive hemorrhage and rapid shock • If the uterus does not remain contracted as a result of uterine massage or if the fundus is displaced, the bladder may be distended. A full bladder lifts the uterus, moving it up and to the side, preventing effective contraction of the uterine muscle. Assist the mother to urinate or catheterize her to correct uterine atony caused by bladder distention. Note urine output Pharmacologic • Early administration of oxytocin is recommended for all births as a prophylaxis against postpartum hemorrhage. IV infusion of dilute oxytocin (not IV push) should be given during the 3rd stage of labor. Oxytocin may also be administered intramuscularly • Methylergonovine (methergine) is a common second drug of choice when oxytocin is not effective. Methergine elevates blood pressure and should not be given to a woman who is hypertensive. • Cytotec may also given to control bleeding. Can be given rectally, sublingually, or orally • A derivative of prostaglandin F2α (carboprost tromethamine [Carboprost; Hemabate]) may be given intramuscularly. It can also be given intramyometrially at cesarean birth or POSTPARTUM intraabdominally after vaginal birth. Prostaglandin E2 (Dinoprostone) vaginal or rectal suppository can be used for postpartum hemorrhage. • Late Causes: • Late occurring between 24 hours and 12 weeks after birth • Rx: Pharmacologic • • • Ergonovine (Ergotrate) or methylergonovine (Methergine), 0.2 mg every 3 to 4 hours for 24 to 48 hours, is often used. Dilation and curettage (D&C) may be performed to remove retained placental fragments or to debride the placental site. If the cause of subinvolution is infection, antibiotic therapy is needed Other Causes • Subinvolution (delayed return of the uterus to its nonpregnant size and consistency) • Retained placental fragments • Infection • Normally the uterus descends at the rate of approximately 1 cm (one fingerbreadth) per day. By 14 days, it is no longer palpable above the symphysis pubis. The endometrial lining has sloughed off as part of the lochia, and the site of placental attachment is well healed by 6 weeks after childbirth. When placental fragments are retained, clots form around the retained fragments, and excessive bleeding can occur when the clots slough away several days after birth • Attempts to deliver the placenta before it separates from the uterine wall, manual removal of the placenta, placenta accreta, previous cesarean birth, and uterine leiomyomas are primary predisposing factors for retention of placental fragments found that early postpartum hemorrhage and advanced maternal age (35 years or older) were also risk factors. Nursing Assessments and interventions • In most cases, subinvolution is not obvious until the mother has returned home after childbirth. Nurses should teach the mother and her family how to recognize its occurrence. Demonstrate how to locate and palpate the fundus and how to estimate fundal height in relation to the umbilicus. The uterus should become smaller each day (by approximately one fingerbreadth). Explain the progressive changes from lochia rubra to lochia serosa and then to lochia alba • Instruct the mother to report any deviation from the expected pattern or duration of lochia. A foul odor often indicates uterine infection for which treatment is necessary. Additional signs include pelvic or fundal pain, backache, and feelings of pelvic pressure or fullness. The mother should be able to verbalize the warning signs before leaving the facility The woman and her family will be anxious about her condition. In an emergent care situation, the nurse can provide brief explanations about interventions being performed and the need to act quickly. Family members will likely be asked to leave the room while the hemorrhage team is intervening. After the event, the nurse can help the woman and her family to understand what occurred and the interventions that were needed. Once the woman's condition is stabilized and she has begun the recovery process, preparations for discharge are made. Discharge instructions for the woman who experienced PPH are similar to those for any postpartum woman. In addition, the woman should be told that she will probably feel fatigue, even exhaustion, and will need to limit her physical activities to conserve her strength. She may need instructions about increasing her dietary iron and protein intake and POSTPARTUM iron supplementation to rebuild lost red blood cell (RBC) volume. She may need assistance with infant care and household activities until she has regained strength. The nurse should assess the mother's anticipated level of support from family and friends and help the mother plan how to ask for help when returning home. Some mothers experiencing a PPH have problems with delayed lactogenesis, insufficient milk production, or postpartum depression (PPD). Interprofessional care for the woman may include lactation consultants, obstetric and pediatric health care providers, mental health providers, social workers, and home care nurses. Referrals for home care follow-up or to community resources may be needed, including lactation support or a postpartum doula service. POSTPARTUM Postpartum Infection or Puerperal Infection Chapter 21 – pgs. 516-518 A term used to describe bacterial infections after childbirth any clinical infection of the genital tract that occurs within 28 days after miscarriage, induced abortion, or birth. The definition used in the United States continues to be the presence of a fever of 38° C (100.4° F) or more on 2 successive days of the first 10 postpartum days (not counting the first 24 hours after birth). Most common infections are UTI and endometritis. Rarely here wound infections with C-sections, episiotomy, or laceration. It is rarely we here septic pelvic thrombophlebitis watch mom's vital signs, right. If you get an increased temperature above 100.4 on two occasions that are six hours apart, then you know that there's probably a parallel infection going on and start start looking for the source. The most common infecting organisms are the numerous streptococcal and anaerobic organisms. Staphylococcus aureus, gonococci, coliform bacteria, and clostridia are less common but serious pathogenic organisms that can cause puerperal infection. Postpartum infections are more common in women who have concurrent For all of these…understand medical or immunosuppressive conditions or who had a cesarean or other the symptoms, treatments, operative birth. Intrapartal factors such as prolonged rupture of membranes, common labs drawn and prolonged labor, and intrauterine monitoring of uterine contractions or fetal heart nursing management rate and pattern increase the risk for infection   Endometritis-An infection of the inner lining of the uterus o Usually begins as a localized infection at the placental site but can spread to the entire endometrium. o The highest incidence occurs in women who gave birth by cesarean after prolonged labor and rupture of membranes. o Prophylactic antibiotics administered during labor and during cesarean surgery can help reduce the incidence and severity of endometritis. o Symptoms  Signs of endometritis include fever (usually greater than 38° C [100.4° F]), increased pulse, chills, anorexia, nausea, fatigue and lethargy, pelvic pain, uterine tenderness, and foul-smelling, profuse lochia. Leukocytosis and a markedly increased RBC sedimentation rate are typical laboratory findings. Anemia can also be present. Blood cultures or intracervical or intrauterine bacterial cultures (aerobic and anaerobic) should reveal the offending pathogens within 36 to 48 hours o Management  Consists of IV broad-spectrum antibiotic therapy (cephalosporins, penicillins, or clindamycin and gentamicin) and supportive care, including hydration, rest, and pain relief  Antibiotic therapy is usually discontinued 24 hours after the woman is asymptomatic.  Assessments of lochia, vital signs, and changes in the woman's condition continue during treatment.  Comfort measures depend on the symptoms and may include cool compresses, warm blankets, perineal care, and sitz baths.  Patient education should include side effects of therapy, prevention of spread of infection, signs and symptoms of worsening condition, adherence to the treatment plan, and the need for follow-up care.  Women may need to be encouraged or assisted to maintain mother-infant interactions and breastfeeding. UTI – urinary tract infection o Most common POSTPARTUM Is mom having pain when she urinates? Okay, let's send a urinalysis because we've probably got a UTI. Urinary tract infections (UTIs) occur in 2% to 4% of postpartum women. Risk factors  urinary catheterization, frequent pelvic examinations, regional (epidural or spinal) anesthesia, genital tract injury, history of UTI, and cesarean birth. o Signs and symptoms  dysuria, frequency and urgency, low-grade fever, urinary retention, hematuria, and pyuria. Costovertebral angle tenderness or flank pain can indicate upper UTI. o The most common infecting organism is Escherichia coli, although other gram-negative aerobic bacilli can cause UTIs. o Management  Medical management for UTIs consists of antibiotic therapy, analgesia, and hydration.  Postpartum women are usually treated on an outpatient basis; therefore, teaching should include instructions on how to monitor temperature, bladder function, and appearance of urine.  The woman should also be taught about signs of potential complications and the importance of taking all antibiotics as prescribed.  Other suggestions for prevention of UTIs include proper perineal care, wiping from front to back after urinating or having a bowel movement, and increasing fluid intake.  Unsweetened cranberry juice or cranberry supplements may be beneficial in preventing UTI.  Mastitis – infection of the breast- occurs most often 2-4 weeks after delivery – although can develop any time with breastfeeding o Won’t hear anything while the pt is in hospital o Occurs 2 to 4 wks after delivery once they start breastfeeding regularly o symptoms such as fever, malaise, flu-like symptoms, and a sore area in a breast  Septic pelvic thrombophlebitis-least common – happens when infection spreads along the pelvic venous system and thrombophlebitis develops  Wound infections-can occur in a c/section incision, episiotomy or laceration o C-section pt can be at the hospital for 3 days o Wound infections are common postpartum infections that often develop after mothers are discharged home. o Women can also develop infection in the perineum in a repaired laceration or episiotomy site. o Signs of wound infection include  fever, erythema, edema, warmth, tenderness, pain, seropurulent drainage, and wound separation. o Management  Culture of wound exudate is performed to identify the causative organism.  Wound infections are treated with intravenous antibiotic therapy. When pus is present in the incision, the wound is opened and drained. Wounds are irrigated with normal saline and redressed several times daily; healing occurs by secondary intention. In some cases, a wound vacuum device is used. Antibiotic treatment is continued until the base of the wound appears clear and there are no apparent signs of cellulitis  Nursing care includes frequent assessments of temperature and vital signs; wound assessment and care; and comfort measures such as analgesics, sitz baths, warm compresses, and perineal care. o o o POSTPARTUM Teaching includes hygienic care techniques (e.g., changing perineal pads front to back, hand hygiene before and after perineal care), self-care measures, and signs of worsening conditions to report to the obstetric health care provider.  Wound care and assessment will continue after discharge from the birthing facility. The woman and her family are instructed in how to perform wound care and dressing changes.  Home visits by nurses may be provided to assess the wound, reinforce teaching, and offer support. If intravenous antibiotic therapy is continued in the home, it is likely to be administered by the family with regular monitoring by the visiting nurse 