Postpartum

Returning of uterus to pre-pregnancy size

decreased cell size and exfoliation-scaling off of dead tissue and regrowth of endothial tissue w/o scarring at site of attachment

Level of fundus at 24h-umbilicus
Down 1cm/day

-increased breast feeding quickens involution
-full bladder, atony and clots slow down involution

to not only look at fundus but with lochia and other risk factors

Fundus above Umbilicus

Accumulation of clots

Prolonged labor

Fundus above Umbilicus
Boggy
Deviated to one side
Not on schedule

Accumulation of clots
Full bladder

Prolonged labor
Parity > 5
Over-distention of uterus
Retained products of conception.

Usually means she has a full bladder

Lochia rubra-dark red, some clots lasts 2-3 days
Lochia Serosa-Pink, ppd 3- ppd 10(may see earlier with c/s)
Lochia Alba-yellowish 1-2wk more

Decreases in volume
Odor is musty-not foul
>flow w/ breast feeding/ in the am
Lighter in color each day

increased volume
foul odor
serosa to rubra

increased volume and color-tell mom to slow down

increased volume, increased color and odor

flabby, open 2cm, closes in about 2 wk,if cervix is lacerated see firm fundus with > bleeding

edematous and bruised. will return to ruggae in few weeks

edematous from trauma

maternal passivity and dependence. mom preoccupied with own needs. may not be interested in baby for mins to days. NORMAL

more focus on self care and baby care. less dependence on others. GOOD TIME FOR TEACHING

Post partum period see high levels of hormones suddenly drop causes abrupt change in hormone levels
exhaustion

hx-planned, prenatal visits, education, moms thoughts
RX-esp if breast feeding
Rubella status
Rh status

Mom carries excess fluid that needs to be gone: profuse sweating esp at night. diuresis.
linea nigra starts to fade
striae-bright red to silvery

SVD-resume normal diet
c/s- sips and chips to +BS and flatus
continue with PNV for 6wks
if breast feeding drink to thirst

No restrictions but certain foods may make baby fussy. watch what you eat and how baby reacts. If you eats these foods during preg infant already starts to tolerate

DONT DIET avg loss 25-30# 6wk appt. DO NOT DIET

SVD- abd is doughy and no tone, assess for rectis abdominus (may nn PT if severe)
C/S- assess BS, flatus, distention.
Common to see hemorrhoids- note number and size

risk for retention due to trauma of urethral site or swelling. May not feel urge to void. W/I 24h should see diurisis.

b/c a full bladder causes the uterus to be higher and off to one side causing the uterus to be soft
*a risk for hemorrhage*

Adlib
VS- BP should return to Prepreg, pulse slower at 50-70bpm, resp the same, temp may raise as high as 100.4 normal (WBC also go up)

Risk for thrombophlebitis due to state of hypercoaguablity

initially wired then crash
encourage to rest when baby sleeps
cluster nursing care
discourage massive visitors causes overstimulation for baby and no sleep for mom

self-care- what is going to happen to fundus, peri care, exercise, sleep, *birth control*
Infant care-feeding, diapers

Perineal- ice 12-24h, motrin and peri bottle
Afterbirth- failure of uterus tos tay contracted, increases with every delivery, strongest when breast feeding
cord care, bulb syringe, infant safety

important not to discourage father in what he is doing, ler himbe and do it in his own way

Klaus and Kennel- feedback cycle important for baby to give feedback to mom

Assess-duration of labor, type of delivery, condition of baby, anesthesia/analgesia, EBL, check H&H
BIRTH CONTROL
Resumption of intercourse

BUBBLE
breast, uterus, bowels, bladder, lochia, episiotomy or laceration on perinum

uniformly soft 2-3 days
assess for hardness, redness and cracks *address immediately* Teach-supportive bra, warm h2o stimulates let down, use of cabbage levels helps if you don't want to BF

remember to support cervical neck when palpating fundus

Full bladder=atony. Keep empty
Bowel-use of stool softners help overcome fear of first BM

Assess:amount;heavy soaks pad in 1h, moderate 4-5in/hr, light, 2-3in/hr, scant
note size and amount of clots
*anything above moderate NOT NORMAL*

ASSESS: edema, ecchymosis, hemrrhoids. lg area of bruising may mean hematoma
TEACH: use of ice, peri bottle, spray (tucks)

ATTACHMENT, risk for impaired
Fluid bolume deficit risk(hemorrhage)
pain, acute
Urinary elimination impaired
sleep pattern disturbed
risk for infection

ETIOLOGY;80-90% uterine atony

overdistention
prolonged/precipitous labor
high parity
interventions(pitocin,tocolytics, general)

boggy uterus
dark red bleeding
large clots

fundal massage
IV access-replaces fluid/blood transfusion
Meds
Bimanual uterine massage
surgery-last resort

Oxytocin- dose for pph; iv 10-40units added to 1000cc, IM 10units
S/E; anaphylaxis, HTN, N/V, >cramps
monitor I&O, lochia, fundus

dose; IM 0.2 mg q 2-4hrs slow push, PO 0.2mg TID or QID
S/E: >BP, HA, dizziness, palpaitations, >cramps

both stimulate smooth muscles of uterus so they can contract. Oxy is intermittent and meth is continuous. never use either with PERCADAN

prostaglandin
dose: IM 250ug/ml deep IM q 1 1/2 - 3h(may be injected transabd into uterus by MD)
S/S: n/v, diarrhea, fever, chills
use with caution if hx of bronchospasms

cervix/uterus/vagina

forceps, vacuum, prolonged or precipitous delivery, pushing before 10cm, malnutrition(poor turgur)

firm fundus, bright red bleeding
firm fundus and hvy lochia suspect uterus laceration call md

visualize and repair

occurs if placenta does not seperate after one hour. remove under general can be done with hand. Increased risk of PPH and infection

risk: episotomy, prolonged second stage

pain more than expected, localized blue or red swelling, vaginal or rectal mass on palpation

observe, ice or drain and treat with antibiotics

obesity, >age, >parity, hx of thrombosis or anemia

superficial-redness, pain and heat, +/- fever, +/- homans. tx-elevation, ted, analgesics
Deep vein- leg or pelvic, fever/chills, < pedal pulses, milk leg (cool and pale) tx with heparin, bedrest and analgesic

freq vaginal exam, anemia, pph, retained placenta, c/s

local, endometritis most common site is wher placenta implants, PID, peritonitis, sepsis

lochia-will increase and be foul smelling
fever/chills
abd pain

analgesic, abx, assess for pariliticilleus

Breast infection, usually S. auerus, coming from baby;s resp system when feeding
occurs most freq in primips and usually infects one breast

>temp with chills, malaise, tachy, headache, tender breast with reddened area.
SYSTEMIC REACTION

antibiotics frequent nursing(helps keep engorgment to a min) heat and analgesics

transient and normal occurs in 50-80% of woman usually occurs 3-4d PP

crying jags, anxiety, labile, fatiques, "muddled thinking"
tx: support, normalize it

Can happen anytime after birth *SERIOUS acute Depression, occurs in 10-15%
lasts up to 6 monthes or longer
woman who have hx of depression or a sick baby are more at risk

sleep disturbances, less energy, change in appetite, crying and feelings of worthlessness, thoughts of suicide

therapy-supportive, antidepressents-almost always
may be hospitalized until stable.

very rare, 0.01%
high rate of reoccurance

chemical, >sensitivity of hypothalmic dopamine D2 recptors(?)

delusins, hallucinations, disorganized or catatonic behavior, loosening of associations esp around themes of childbirth

10days -8wks

Seperate mom and baby!! most woman have thoughts of harming baby before do it. be aware. hospitalization, anti-psychotic meds and follow up with future preg

exclusive BF to 6mo and the supplement with solids and continue to BF to 1yr

<diarrhea, uti's, pneumonia, otis media, celiac disease, chron's, meningitis,a sthma, allergies, sids,lymphoma, leukemia, IDDM, childhood obesity

< breast CA, PPH, weight retention, $ spent on formula, conveince may lessen risk for osteoporosis

HIV+, serious illness, drug therapy

L1-safest
L2-safer
L3-mod. safe
L4-hazardous
L5-contraindicated

prolactin- suckling produces for ilk production
Oxytocin-for let down

colostrum-rich but low volume called liquid gold due to high levels of antibodies
fore milk-tend to have more h2o
hind milk-high in fat and calories
new thought is to nurse on one side until empty so infant gets the hind milk.

Feeding clues:rooting, hands to mouth, sucking
Clues are given before screaming, pay attention!

the baby is not properly latched on

correct postion +1
baby latched on +1
baby sucking +1
audible swallowing heard =1
TOTAL SCORE 4