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Postpartum Physiological Changes, Exams of Nursing

A.T. Still University of Health Sciences (ATSU)Nursing

A detailed overview of the various physiological changes that occur in the postpartum period, including changes to the reproductive system, integumentary system, immune system, breasts, extremities, and cardiovascular system. It covers topics such as cervical and vaginal changes, episiotomy care, postpartum sexual activity, skin changes, immune system changes, breast engorgement, and blood volume and component changes. The nursing interventions and considerations for each of these areas are also discussed, making this a comprehensive resource for understanding the postpartum recovery process. The information presented could be useful for healthcare professionals, students, or individuals interested in the postpartum period.

Typology: Exams

2023/2024

Available from 10/16/2024

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NURS 3358 Exam 2 Study Guide Postpartum Care And Postpartum

Complications”

Nursing Process

•Initial Assessment

oPhysical – body Systems and lab work

▪CBC and lab work can show how much blood she has lost.

oPsychosocial

•Development of Nursing Care Plan – physical and educational needs

•Nursing Diagnoses

oRisk for bleeding / Risk for fluid volume deficit

oRisk for impaired CO / Risk for decreased tissue perfusion

oRisk for infection

oAcute pain

oKnowledge deficit R/T self-care, newborn care, or breastfeeding

oBreastfeeding, ineffective or interrupted

oAlteration in bowel or urinary elimination

oRisk for impaired attachment or impaired parenting

oDisturbed sleep patterns

•Expected Outcomes

oInvolution and return to pre-pregnancy state will be accomplished without complications

oParental roles will be successfully assumed

oNew baby will be successfully integrated into family structure

oSuccessful infant feeding patterns will be established

•Plan of Care

oOrientation to the unit

oPrevention of excessive

bleeding

▪Maintenance of uterine tone

▪Prevention of bladder distention

oPrevention of infection

oPromotion of comfort, rest, ambulation, and exercise

oPatient teaching:

▪Self-care

▪Newborn feeding and care

•Interventions

oLab work: CBC, Rubella titer

oMedications:

▪Iron/prenatal vitamins

▪Analgesics

▪RhoGAM administration (if Rh negative)

▪Rubella Titer (if not immune) – 1:8 = immune

▪Vaccines: Varicella, Tdap

▪Depo-Provera or other contraceptives

•Evaluation of Outcomes

oInvolution successfully initiated and progressing without complication

▪Uterus returning back to its pre-pregnant state.

oParents begin to assume new role behaviors and identities

oBeginning integration of newborn into family structure; bonding established

oInfant feeding techniques mastered

oParents comfortable with infant care

Postpartum Assessment:

•Six B’s: Bleeding, Breasts, Bladder, Bowels, Bottom, Bonding

Discover Exams of Nursing A.T. Still University of Health Sciences (ATSU)

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NURS 3358 Exam 2 Study Guide Postpartum Care And Postpartum

Complications”

Nursing Process

Initial Assessment o Physical – body Systems and lab work ▪ CBC and lab work can show how much blood she has lost. o Psychosocial
Development of Nursing Care Plan – physical and educational needs
Nursing Diagnoses o Risk for bleeding / Risk for fluid volume deficit o Risk for impaired CO / Risk for decreased tissue perfusion o Risk for infection o Acute pain o Knowledge deficit R/T self-care, newborn care, or breastfeeding o Breastfeeding, ineffective or interrupted o Alteration in bowel or urinary elimination o Risk for impaired attachment or impaired parenting o Disturbed sleep patterns
Expected Outcomes o Involution and return to pre-pregnancy state will be accomplished without complications o Parental roles will be successfully assumed o New baby will be successfully integrated into family structure o Successful infant feeding patterns will be established
Plan of Care o Orientation to the unit o Prevention of excessive bleeding ▪ Maintenance of uterine tone ▪ Prevention of bladder distention o Prevention of infection o Promotion of comfort, rest, ambulation, and exercise o Patient teaching: ▪ Self-care ▪ Newborn feeding and care
Interventions o Lab work: CBC, Rubella titer o Medications: ▪ Iron/prenatal vitamins ▪ Analgesics ▪ RhoGAM administration (if Rh negative) ▪ Rubella Titer (if not immune) – 1:8 = immune ▪ Vaccines: Varicella, Tdap ▪ Depo-Provera or other contraceptives
Evaluation of Outcomes o Involution successfully initiated and progressing without complication ▪ Uterus returning back to its pre-pregnant state. o Parents begin to assume new role behaviors and identities o Beginning integration of newborn into family structure; bonding established o Infant feeding techniques mastered o Parents comfortable with infant care Postpartum Assessment:
Six B’s: Bleeding, Breasts, Bladder, Bowels, Bottom, Bonding

• BUBBLEHE

o Breasts o Uterus o Bladder o Bowel o Lochia o Episiotomy o High risk clots o Emotional Postpartum Period:

Scant, light, moderate, or heavy
Should not have clots larger than a dime
Anticipate increased flow the first time the woman ambulates or breastfeeds; may feel a gush – do not confuse with a hemorrhage
The amount may increase upon standing after sleeping, due to pooling in the vagina/uterus
Large or excessive clots indicates possible uterine atony and hemorrhage
The amount may be less in C/S mothers, but the stages remain the same (rubra  serosa  alba)
May feel gush with breastfeeding

Total amount: 240-270 cc ▪ Normal odor is the same as menstrual flow – call MD if odor becomes foul smelling ▪ DANGER SIGNS:
Reappearance of bright red blood after rubra has stopped
Persistence of lochia rubra – possible retained placental fragments or membranes
Sudden, but brief, increase in bleeding 7-14 days after birth can occur due to sloughing of eschar over placental site
Notify provider if does not subside within 1-2 hours
10%-15% women have normal lochia serosa at 6 week visit
Continued flow of serosa or alba by 3-4 weeks postpartum can indicate endometritis, especially with fever, pain or abdominal tenderness
Not all vaginal bleeding is lochia!! Differentiate between lochia and vaginal, cervical or uterine tear that needs repair ▪ Box 20-1 Lochial and Nonlochial Bleeding
Lochial: o Lochia usually trickles from the vaginal opening, with the steady flow increasing as the uterus contracts o A gush of lochia can appear as the uterus is massaged o If it is dark in color, it has been pooled in the relaxed vagina o Amount soon lessens to a trickle of bright red lochia (in the early puerperium)
Nonlochial: o If the blood discharge spurts from the vagina, and the uterus is firmly contracted, there can be cervical or vaginal tears in addition to the normal lochia o If the amount of bleeding continues to be excessive and bright red, a tear can be the source ▪ Uterus and Lochia Assessment
Uterine and lochia assessment is ALWAYS assessed together
Consider parity, size of baby and gestational age, size of mother, length of labor, use of oxytocin, bladder status
Differentiate between lochial and non-lochial bleeding – is there a tear or laceration?
Cervix o Immediately after birth: ▪ Spongy, flabby, bruised, with small lacerations – risk for infection! ▪ Over the next 12-18 hours, it shortens and becomes firmer o Closes slowly – admits 1 fingertip by 1 week postpartum o Shape of the cervical os does not return to normal round dimple, but instead changes to a slit
Vagina o Edematous and bruised with superficial lacerations o Not all lacerations sutures o Rugae is obliterated – vaginal wall with be smooth for 3-4 weeks ▪ Rugae will reappear, although not as prominent as pre-pregnant o Hypoestrogenic until ovulation and menstruation resume ▪ Estrogen deprivation responsible for the thinnest of the vaginal mucosa and absence of rugae
Perineum o Perineal lacerations ▪ 1 st^ degree – skin & superficial tissue ▪ 2 nd^ degree – extends through muscles ▪ 3 rd^ degree – continues through anal sphincter muscle ▪ 4 th^ degree – involves anterior rectal wall
Nursing interventions: o Assess site, keep clean, ice packs, analgesics o Teach pt comfort measures, high fiber diet, stool softeners, increased fluids (3rd/4th^ degree) o Episiotomy o Hemorrhoids o Hematoma o Perineal Comfort Measures
Ovulation and Menstruation o Non-lactating Mothers: ▪ Period returns as early as 27 days after birth

▪ Assess for s/s of abnormal bleeding ▪ Report abnormal findings ▪ Teach Kegel exercises (pg. 92) ▪ Use of water-soluble lubricant when resuming sexual relations o Episiotomy ▪ Document if midline or mediolateral (right or left) ▪ Assess episiotomy for REEDA-D

Redness
Edema
Ecchymosis
Approximation
Discharge ▪ Assess for tears or lacerations ▪ Teach mother that healing takes about 2 weeks ▪ If perineum is intact – assess for ecchymosis and edema o Comfort Measures for “Bottom” ▪ Ice packs for the first 24 hours ▪ Analgesia:
Oral meds and/or topical meds (foam or spray) ▪ Perineal care performed with peri-bottle and water with blot drying from front to back each time woman voids or stools ▪ Positioning:
Crawl into bed
Perform Kegel before sitting
Lie on side ▪ Take stool softener ▪ Tucks – also helps with hemorrhoids ▪ Sitz bath (after first 24 hours) ▪ Hospital gown should be worn at least for the first day o Pharmacologic Pain Relief ▪ Opioids: Percocet, Meperidine, Morphine
A PCA pump is often ordered for C/S patients ▪ NSAIDs: Naproxen Sodium
Toradol or Ketorolac for C/S moms ▪ Topical antiseptic, anesthetic spray or ointment for pain o Postpartum Sexual Activity ▪ Follow primary HCP orders ▪ Pelvic rest for 6 weeks****
Can increase risk for intrauterine infection because placental site doesn’t heal for 6 weeks ▪ Abstain until episiotomy has healed, lochial flow has stopped, and there is no vaginal discharge
If there is a vaginal discharge, they should remain from having sex ▪ Use an additional lubricant (dryness is a result of hormonal deficit) ▪ Contraceptive/family planning should be considered ▪ Body image concerns; breastfeeding; exhaustion ▪ Consider different positions for comfort; encourage creativity! J Musculoskeletal System
Abdomen o Abdominal muscles are relaxed for the first 2 weeks after birth and the return of pre-pregnancy muscle tone takes about 6 weeks o Diastasis recti abdominis – condition where the abdominal wall muscles separate with large fetus or multifetal pregnancy ▪ Becomes less apparent with time o The abdomen may still appear pregnant o Joints stabilize by 6-8 weeks o Feet may permanently remain a larger shoe size o Do postpartal exercises

Integumentary System

Most skin changes during pregnancy resolve following pregnancy
Melasma (chloasma)-persists in 30% women
Hyperpigmentation of areola & linea nigra
Striae gravidarum – lighten, regress in size
Spider angiomas (nevi) – may persist
Palmar erythema regresses
Hair loss; fine hair from pregnancy disappears
Nails return to prepregnant status

o Evaluate face, hands, and feet for edema Cardiovascular System

Blood Volume o Normal blood loss for a delivery:

▪ Vaginal birth = approximately 300-500 ml ▪ Cesarean birth = approximately 500-1000 ml o Blood loss is tolerated well due to the increase of blood volume by 30-50% during the pregnancy

Blood Components o Hematocrit returns to normal at 8 weeks, lower expected immediately after birth ▪ After birth, Hct drops moderately due to blood loss ▪ Begins to increase after 3-4 days postpartum o WBCs decrease back to normal range ▪ Normal leukocytosis during pregnancy = approximately 12,000/mm ▪ During first 10 days postpartum = approximately 20,000-25,000/mm o Clotting factors and fibrinogen are normally increased during pregnancy and remain elevated during the early postpartum period ▪ Vessel damage (endothelial injury), immobility (stasis) and hypercoagulability of pregnancy (Virchow’s Triad) increases risk for thromboembolism, especially after a cesarean section and with obesity. o Increased blood viscosity increases the risk of thrombophlebitis
Varicosities of the legs and around the anus have total or nearly total regression in the puerperium period Neurologic System
Pregnancy-induced discomforts disappear after birth o Carpal tunnel o Numbness and tingling in fingers o Tinnitus o Laryngeal changes
Headaches are common in the first postpartum week o Requires careful assessment in distinguishing the cause: ▪ Stress-related headaches ▪ Preeclampsia ▪ Leakages of CSF following epidural or spinal anesthesia Endocrine System
Expulsion of the placenta  decrease in estrogen, progesterone, cortisol, and insulinase o Insulinase reverses the diabetogenic effects of pregnancy  significantly lower blood glucose levels in the immediate puerperium o Mothers with T1DM will likely require much less insulin for several days after birth o Goal: keep glucose level 65-95 mg/dl
Prolactin levels rise progressively throughout pregnancy, and after birth will increase further (as progesterone decreases) o Breastfeeding maintains high prolactin levels (highest in the first month) o Non-lactating women decline to normal prolactin levels about 3 weeks after birth
Many women ovulate before their first postpartum menstrual period o Important to discuss contraception options during early postpartum period Gastrointestinal System
Woman are usually hungry post-birth o A good appetite is normal
May not have BM for 2-3 days’ post-birth o Constipation from lack of abdominal/GI muscle tone o Perineal soreness o Side effects of narcotics, magnesium sulfate, immobility, dehydration, and iron supplements (taken before arrival)
Nursing Interventions o Assess bowel sounds, pattern of elimination, and hemorrhoids o Diet: ▪ Increase liquids and fiber ▪ Require 1800-2200 kcal diet ▪ Breastfeeding mothers require:
Additional calories (400-500 kcal)

o Profuse diuresis (and diaphoresis) occurs for the first 2-3 days to rid excess interstitial fluid (profuse diaphoresis as well) ▪ Commonly 3000 ml/day of urine output

Birth-induced trauma: decrease urge to void. Bladder tone restored 5-7 days pp with adequate emptying.
Urethra and Bladder o With adequate emptying, bladder tone is usually restored 5-7 days postpartum o Post-delivery: birth-induced trauma to the bladder, urethra, and urinary meatus is common ▪ Results in a decreased urge to void  urinary retention may occur o Elevated or laterally displaced uterus is a common sign of urinary retention (catheterize post-epidural) o Bladder distention may cause uterine atony and postpartum hemorrhage!!!
Nursing Interventions: o Assess for bladder distention, burning, pain, or difficulty voiding o Encourage voiding: ▪ Run water in basin ▪ Provide aromatherapy with peppermint ▪ Provide PRIVACY o Encourage early ambulation o Ensure adequate fluid intake o Offer warm sitz bath (if needed) o DOCUMENT FIRST VOID o Catheterize woman post-epidural to empty the bladder in the event of urinary retention Cesarean Births
Additional Assessments o Cardiovascular: increased blood loss o Integumentary: abdominal incision o Renal: Foley catheter o Gastrointestinal: increased gas pains o Discomfort while breastfeeding o Increased pain from incision o Obesity increases risk for abdominal incision infection
Nursing Interventions o Monitor closely at least 2 hours post C/S while in recovery o Assess abdominal dressing/incision o Assess urine output after Foley catheter is discontinued o To relieve abdominal distention and gas pains: ▪ Encourage early and frequent ambulation ▪ Avoid carbonated beverages ▪ Delay in regular diet until bowel sounds are heard o Use pillow to assist with breastfeeding o If pain increases, put on PCA pump o Routine surgical care: ▪ Sequential Compression Devices ▪ Turn, Cough, Deep Breathing

Postpartum Complications

Postpartum Hemorrhage (PPH) o Coagulopathies o Thromboembolic disease o Postpartum infection ▪ Endometritis ▪ Wound infection ▪ UTI ▪ Mastitis o Postpartal mood disorder

o A major cause of maternal death o The loss of > 500 ml after vaginal birth or > 1000 ml after C/S; a 10% change in hematocrit from admission for labor and postpartum or the need for erythrocyte transfusion o Early PPH (within 24 hours after birth) – Primary or Acute PPH o Late PPH (post 24 hours, usually < 6 weeks after birth) o Uterine Atony – marked hypotonia of the uterus in the first hour after birth; poor uterine contraction due to overstretching or other causes ▪ Leading cause of PPH, complicates 1:20 births ▪ Predisposing factors:

Over-distention of the uterus / large baby

Elimination of bladder distention
Continuous infusion of LR with 10-40 units of oxytocin (Pitocin) ▪ If uterus still not contracted, give:
Methergine (contraindicated with HTN, preeclampsia, cardiac disease)

o Note: some hospitals delay breastfeeding if methergine is administered

Hemabate (contraindicated with asthma and HTN)
Cytotec (contraindicated with allergy prostaglandins) ▪ Lactated Ringers IV solution 3:1 ratio
Fluid replacement of 3 cc for every 1 cc of blood lost ▪ Blood products
Packed RBCs or fresh frozen plasma ▪ Dilation and curettage (D&C) to remove retained placenta or membrane pieces o Nursing Interventions ▪ Assess for hypovolemic shock – vitals and s/s
**Respirations, pulse increased
Patient’s behavior – change in LOC, restlessness, sense of impending doom**
Decreased BP (late sign) ▪ Monitor fundus consistency and bleeding ▪ Administer medications and IVF/blood as ordered ▪ Monitor oxygen saturation with pulse ox ▪ Insert Foley if ordered and monitor I&O hourly ▪ Assist in calming the patient and family
Coagulopathies o Disseminated Intravascular Coagulation (DIC) ▪ A paradoxical condition in which clotting & hemorrhage occur within the vascular system simultaneously. ▪ Obstetrical causes: abruptio placentae, amniotic fluid embolism, dead fetus (retained 6 wks), severe preeclampsia, retained placenta, missed/septic abortion, hydatidiform mole, septicemia, cardiopulmonary arrest, and hemorrhage ▪ Clinical Findings:
Unusual bleeding from gums, nose, venipuncture site, injection sites, or from shaving nicks
Petechiae at BP cuff site
Tachycardia
Diaphoresis ▪ Labs:
Platelets, fibrinogen, fibrin degradation products, PT, special clotting factors, and many more ▪ Medical Management:
Correct the underlying cause (for hemorrhage)
Volume replacement
Blood components
Oxygen ▪ Nursing Management:
Assess for bleeding and signs of complications
Administer fluids and/or blood products
Assess hourly urine output
Provide emotional support to the patient and her family o Idiopathic Thrombocytopenic Purpura (ITP) - autoimmune disorder that decreases the lifespan of platelets ▪ Resulting in:
Low platelet count
Capillary fragility
Increased bleeding time ▪ Increased risk of postpartum uterine bleeding and vaginal hematomas ▪ Neonatal problems are possible as well o Von Willebrand Disease – a type of hemophilia caused by defect in vWD factor ▪ Symptoms:
Nose bleeds
Bruising
Prolonged bleeding time
Factor VIII deficiency ▪ Increased risk for bleeding up to 4 weeks postpartum
Venous Thromboembolism (VTE) o Results from the formation of a blood clot (thrombus) caused by: ▪ Inflammation (thrombophlebitis) ▪ Partial obstruction of the blood vessel

▪ Possible genetic link o The woman is at risk for thrombophlebitis during postpartum ▪ Check for redness, tenderness, and warmth of her calf ▪ Avoid having the patient remain in bed throughout the day

Encourage ambulation to prevent stasis of blood in lower leg veins ▪ SCDs if on prolonged bed rest o Superficial Venous Thrombosis (SVT) – involves superficial saphenous venous system ▪ S/S (start around day 3-4 postpartum):
Tenderness is apparent in a portion of the vein
Area over the vein may be hardened
Local heat and redness present
May have low grade fever
PE is very rare ▪ Treatment:
Non-aspirin analgesia
Rest with elevation of the affected leg
Elastic stockings
Local application of heat o Deep Vein Thrombosis (DVT) – occurs most often in lower extremities; involvement varies but can extend from the foot to the iliofemoral region ▪ More common in pregnancy; women frequently have a history of thrombosis ▪ S/S:
Unilateral leg pain
Calf tenderness
Edema
Initial low grade fever followed by chills and high fever
Peripheral pulses may be decreased
May result in PE ▪ Treatment:
Immediate Medical Treatment: o Anticoagulant therapy – usually continues IV Heparin ▪ Antagonist – Protamine Sulfate o Bed rest with affected leg elevated o Analgesia with non-aspirin o Elastic stockings after symptoms decrease o Oral anticoagulant (warfarin/Coumadin) for 3 months ▪ Antagonist – vitamin K o Pulmonary Embolism (PE) – complication of DVT occurring when part of the blood clot dislodges and is carried to the pulmonary artery, where it occludes the vessel and obstructs blood flow to the lungs ▪ S/S:
Hypotension
Dyspnea
Hemoptysis
Chest pain ▪ Treatment:
If patient experienced a PE, anticipate treatment with continuous IV Heparin therapy until symptoms resolve
Continue intermittent subcutaneous Heparin or oral anticoagulant therapy for 6 months o Nursing Prevention/Management ▪ Assessments
Inspect site
Palpate peripheral pulses (Homan’s sign)
Daily measurement and comparison of leg circumferences
Signs of bleeding
Signs of PE ▪ Evaluate laboratory results ▪ Promote increased fluid intake ▪ Maintain bed rest as ordered

▪ When patient is able to get up, avoid standing or sitting for long periods of time – TEACHING OPPORTUNITY ▪ Avoid elevating sharply flexing knees ▪ Elevate leg on pillow ▪ Promote comfort

Position change
Non-aspirin analgesia
Rest and sleep

Postpartum Physiological Changes, Exams of Nursing

Related documents

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Download Postpartum Physiological Changes and more Exams Nursing in PDF only on Docsity!

NURS 3358 Exam 2 Study Guide Postpartum Care And Postpartum

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• BUBBLEHE

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