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Postpartum (1)

Postpartum (1)

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Published by: EMz Osain on Apr 04, 2012
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POSTPARTUM

Definitions
 Postpartum
Period from delivery of the placenta & membranes until the involution of uterus is complete, usually 6 weeks post delivery

 Involution
The return of the uterus to normal size after childbirth

 Subinvolution
Incomplete return of the uterus to normal size after childbirth

Physiologic and Physical Changes
A review

Cardiovascular system changes Hypervolemia during pregnancy allows woman to withstand blood loss at delivery Cardiac output remains elevated for 48º postdelivery Cardiac output decreases to normal levels by 24 weeks postdelivery .

2 things occur: Diuresis Diaphoresis .As the body rids itself of the excess plasma volume it’s accumulated during pregnancy.

Plasma fibrinogen (coagulation/clots) increases during pregnancy Plasminogen (lysis of clots) does not  mobility Therefore. higher risk for thrombus formation .

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Gastrointestinal System Bowel tone remains sluggish for the first few days Restricted food/fluids in labor Perineal trauma/hemorrhoids Result could be constipation .

jp .com www.aafp.www.mediawars.ne.

Urinary system  Trauma during delivery could cause swelling of the urinary meatus  Decreased sensation of having to void could cause urinary retention/stasis – could lead to a UTI  Urinary retention/bladder distention a primary cause of excessive bleeding Displaced uterus results in inability of uterus to contract (atony) .

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causing pelvis to return to prepregnant position = hip/joint pain Abdominal muscles weak/flabby Diastasis recti .Musculoskeletal system Levels of hormone relaxin decrease.

but don’t completely go away! .Integumentary system Decrease in melanocyte-stimulating hormone causes a decrease or disappearance of chloasma or linea nigra Striae gravidarum fade to silvery lines.

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report to anesthesiologist Could be due to development or worsening of PIH/preeclampsia. especially if accompanied by blurred vision/ photophobia/abdominal pain .Neurologic system Investigate headache! Could be secondary to regional anesthesia….

Breast Changes If breastfeeding. blisters. cracked and bleeding nipples . improper baby positioning may result in redness.

Breast Engorgement Breastfeeding or bottlefeeding .

Thrush .

U-2.) • Usually not palpable by day 10 .Uterine involution Immediately after delivery – uterus is midway between symphysis and umbilicus Then rises to the umbilicus where it remains for about 24 hours Then gradually descends (  1 cm/day—or one fingerbreath ―fb‖ per day) • Document in terms of umbilicus (U. etc.

not overly tender  Pain/infection or full of blood  Massage and check amount of lochia Don’t over massage…overstimulation can cause atony! . void  Feel fundal height related to umbilicus If fundus is displaced to side may be full bladder  Should feel firm.Assessing Uterus  Have pt.

Assessing Uterus Palpating fundus of uterus during the fourth stage of labor .

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Calif.) . RNC. Lifecircle.Assessing Uterus Assessment of involution of uterus after childbirth– 2 days after childbirth (Courtesy Marjorie Pyle. Costa Mesa.

) . Costa Mesa. Calif.Assessing Uterus Assessment of involution of uterus after childbirth– 4 days after childbirth (Courtesy Marjorie Pyle. Lifecircle. RNC.

greatly improved by 4-7 days  By 6 weeks pelvic floor has regained tone. sutures are absorbed. perineum is healed .Vagina and Perineum  Introitus stretched and gaping  Hemorrhoids and edema  by 2-3 days as circulation and movement   Episiotomy/perineal discomfort most marked 2-3 days PP.

Lochia Vessels at the placental site become thrombosed and slough into lochia (uterine discharge of the puerperium) .

Normal progression Rubra (red): from delivery to 2-3 days PP Serosa (pink/brown):median duration is 22 days. but can still be present at 6 weeks exam Alba (white/yellow): follows serosa .

Variations in lochia Common to have 1-2 hours of bright red flow when eschar sloughs Red lochia after 2 weeks subinvolution/retained placenta Subinvolution • Slower rate of involution • Can be from retained products/placental fragments. atony. clots. infection .

Lochia Lochia should not exceed moderate amount 4-8 pads/day If heavy bleeding or large clots may need to prescribe methergine po .

Light: < 4 inch stain 1 hr. .Scant: 1 inch in 1 hr. Heavy: Saturated pad in 1 hr. Moderate: < 6 inch 1 hr.

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Episiotomy  Perineum may be swollen  May have lacerations or episiotomy  Observe for:  REEDA redness edema ecchymosis/bruising discharge approximation .

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Emotion Baby Blues Postpartum Depression Postpartum Psychosis Postpartum Panic Disorder Postpartum Obsessive-Compulsive Disorder .

Psychological Changes Labile emotions following birth Range from mild forms of feeling sad with frequent crying to full blown psychosis .

Physiologic bases Rapid hormone shifts as body returns to nonpregnant state Fatigue Discomfort .

Psychological bases Sense of physical loss that may result in a mild grief reaction Loss of center stage Feelings of insecurity .

Levels Blues – 1-10 days after birth…weepy Depression – lasts at least 2 weeks…tense. bipolar or major depression . sees infant as demanding. feels inept at mothering Psychosis – rare. within 3 weeks pp. irritable. sleeplessness.

pituitary hormone prolactin disappears in about 2 weeks. HCG If not breastfeeding. . progesterone.Endocrine system Placental hormones decline Estrogen.

Ovulation and menstruation Non-breastfeeding: usually resume periods within 7-9 weeks post delivery Breastfeeding (6 or more times/day): usually resume periods by 12 weeks post delivery Ovulation usually occurs BEFORE menses resumes….don’t rely on breastfeeding for contraception! .

Postpartum Rounds Examine chart for: Time of delivery Type of delivery Episiotomy/lacerations Complications Infant feeding method Labs Blood type CBC Rubella .

“BUBBLE HE”  B= Breasts  U= Uterus  B= Bladder  B= Bowels  L= Lochia  E= Episiotomy  H= Homan’s  E= Emotions  Also…assess heart and lungs! .

if not on iron.Postpartum Rounds  Discharge instructions Report symptoms of infection Continue prenatal vitamins and iron If CBC low (< 10. can add it) Pain (especially if multigravida or 3rd or 4th degree lacerations  Choice of pain meds (Motrin 800 mg works well)  Nupercainal ointment/Tucks for hemorrhoids Contraceptive choice?  Can get Depo Provera before leaving hospital  Can start on OCPs after delivery • Progesterone only/mini pill if BF (immediately) • Combined OCPs if bottle feeding (3 weeks) .

Postpartum Office Visit Ask about her delivery Her feelings about it Any complications? .

Postpartum Office Visit General state of mother and family How is she coping with the baby Mood Appetite Exercise activities Rest/sleep Involvement and interest of father Reactions of siblings to new baby .

Postpartum Office Visit Ask about the baby Problems at birth? Problems now? How is feeding going? .

Postpartum Office Visit
Ask her about:
Fever, vaginal bleeding, cramping, discharge, episiotomy pain, breast soreness or discharge, swelling, headaches, urinary symptoms, and bowel movements
Medications currently taking Contraception method desired

Postpartum Office Visit
 Physical exam
 VS  HEENT (as indicated)  Heart and Lungs  Thyroid  Breast exam (review BSE)  Abdomen – diastasis, softness  Extremities – don’t forget homan’s  Perineum inspection  Pelvic exam, including pap smear
 Note lochia  Uterine size – should be normal size and nontender  GC & Chlamydia culture if desires IUD

Postpartum Office Visit
Labs
Thyroid studies, if enlarged 1 hr GTT if had gestational diabetes

Medications
Prenatal vitamins if breastfeeding OCPs if desired

Postpartum Woman at Risk .

Postpartum Hemorrhage Definition: > 500 ml blood loss during the first 24 hours postpartum (vaginal birth) May occur immediately after delivery during the early postpartum period may be “late postpartum hemorrhage” which occurs up to a month after delivery .

Endometritis Caused by bacteria that normally inhabit the vagina and cervix E. Staphylococcus. which encourages bacterial growth . coli. Group B streptococcus Process of delivery causes vagina to change from acidic environment to alkaline.

Symptoms  Fever  Chills  Malaise  Anorexia  Feels like she has the ―flu‖  Abdominal pain  Uterine tenderness  Purulent. foulsmelling lochia  Tachycardia  subinvolution .

e.Risk Factors  History of previous infections  Colonization of lower genital tract pathogens  Cesarean delivery  Trauma (I. vacuum delivery)  Prolonged ROM  Prolonged labor  Multiple vaginal exams/internal monitors  Catherization  Retained placental fragments  Hemorrhage  Poor general health/hygiene  Poor nutritional status  Low SES .

Erythromycin Rest Increase fluids . Zithromax. Doxycycline.Treatment Antibiotics: Cipro. Metronidazole.

Mastitis Inflammation usually due to Staphylococcus Aureus Due to: Poor drainage of milk Tight clothing Missed feedings Milk stasis Lowered maternal defenses .

4° F or higher) Chills malaise Headache Localized area of redness/inflammation .Symptoms Feels flu-like Fatigue Myalgia Fever (100.

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Treatment of Mastitis  Bedrest  Increased fluids  Frequent feeding of infant/empty milk ducts  Supportive bra  Local application of heat  Analgesics  Antibiotics – Dicloxicillin/Ampicillin/Amoxicillin/Augmentin/ Keflex .

Thrush Nystatin suspension Gentian violet Keep nipples clean and dry .

Urinary Tract Infection Overdistention of bladder Decreased bladder sensitivity Increased bladder capacity Trauma. edema Catheterization Bacturia during pregnancy .

Cystitis (Lower Urinary Tract)  E-coli usual organism  Ascending infection from urethra to bladder to kidneys  Get clean catch urine specimen  Bacterial concentration > 100.000 colonies per milliliter/sensitivity  Antibiotics/sulfonamides  Peri-care  Increase fluids/ (3 liters) .

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searo. Initiating hormonal contraception.pdf . http://www. & Prine. R. 74 . L. American Family Physician.who. (2006). 105-12.int/LinkFiles/Pregna ncy_Childbirth_e.References Lesnewski..

SOAP Note Practice .

Having some afterbirth pains. abdomen soft Lochia Rubra/serosa. U-2. Breastfeeding is going well. nipples intact Heart: RR Lungs clear bilaterally Fundus firm. + BM  O: VSS. scant Episiotomy intact without redness or exudate Voiding qs  A: Stable  Afterbirth pains  P: Discharge home  Discharge instructions reviewed  Motrin 800 mg po Q 8 hrs prn .        Breasts soft.Hospital Note  S: Ready to go home. nontender.

no lesions  Uterus: small. siblings adjusting well to new infant.Homans  Perineum: healed. . no CVAT  Extremities: no swelling. Voiding without difficulty and having regular BMs. anteverted  No adnexal masses  Cervix: transverse os. Has not resumed intercourse but desires OCPs.6 Weeks PP Exam  S: Feeling well. no exudate .  O: Thyroid: WNL  Heart: RR  Lungs: CTAB  Abdomen: no diastasis. breastfeeding without difficulty. closed. soft  Back: straight.

RF X3 OK to begin exercise F/U in one year or prn .A: P: normal pp exam Contraceptive needs BSE reviewed Micronor 1 po q day. #3.

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