500mL Blood Loss if Vaginal Childbirth 1gr / 1000mL Blood Loss if C/S 2gr
It is important for the nurse to remember that, as the body’s excess fluid is excreted, the hematocrit may rise because of hemoconcentration.
Maternal plasma volume decreases even further as a result of diuresis.
Circulating levels of estrogen and progesterone decrease dramatically after delivery of the placenta; human placental lactogen, cortisol, growth hormone, and insulinase, also fall.
maternal fatigue.
Patients who received epidural or spinal anesthesia may experience headaches, especially when they assume an upright position. After spinal or epidural anesthesia, headaches may result from the leakage of cerebrospinal fluid into the extradural space.
· Neurological
Fatigue, Discomfort, OXYTOCIN causes sleepiness.
· Renal System, Fluids and Electrolytes
Urinary output 3000mL in 24 hrs. Diuresis occurs after birth.
· Respiratory System
Resp system goes back to normal non-pregnancy state. Progesterone levels drop.
The immediate decrease in intra-abdominal pressure associated with the birth of the baby allows for increased expansion of the diaphragm and relief from the dyspnea usually associated with pregnancy.
· Integumentary System
Changes related to major alterations in hormones, alterations in pigmentation, connective and cutaneous tissue, hair, nails, secretory glands, and pruritus. Most pregnancy-related skin changes disappear completely during the postpartum period, although some, such as striae gravidarum (stretch marks), fade but may remain permanently.
· Cardiovascular System
Maternal cardiac output is significantly elevated above pre-labor levels for 1 to 2 hours postpartum and remains high for 48 hours postpartum. Returns to normal within 2~4 weeks after childbirth.
· Immune System
WBC slightly increased (25.000 count) during labor and birth and remains elevated during the early postpartum period, gradually returning to normal values within 4 to 7 days after childbirth. Rubella shot (MMR if titters are not immune) RhoGAM If Mom (-) and child (+)
· Ovulation
Menstruation usually resumes within 6 to 8 weeks after childbirth in women who are not breastfeeding.
Exclusively breastfeeding moms may not ovulate or menstruate for 3 or more months.
breastfeeding is not a reliable method of contraception.
· Gastrointestinal System
Bowels more active right after birth, mom may become hungry and thirsty . Constipation, a common nursing diagnosis for the postpartum patient, is associated with abdominal discomfort and decreased hunger.
· Musculoskeletal System
Diastasis recti abdominal: separation of the abdominal muscles. N.I Maintain correct posture when lifting, carrying and bathing the baby for at least 12 weeks after birth. Perform modified sit-ups to strength abdominal muscles.
BUBBLE HEB
BREAST: Engorgement
UTERUS: Fundal Heigh- Uterine Placement/ Consistency (Boggy/ Firm)
BOWEL: Gas passing, Constipation, Air can engage in arm (Early Ambulation)
BLADDER: Assess Catheter/Remove Urine color and amount
LOCHIA: COCA Color, Odor, Consistency, Amount.
EPISISOTOMY: Perineum, Hemorrhoids
REEDA Redness, Edema, Ecchymosis, Discharge, Approximation.
Homans Sign: Calf + Pushing test
Emotions: Affect, family interactions, Baby Blues
Bonding: Gazing, Enfolding, Interaction with the Newborn.
Assessment of Lochia Flow:
Scant: 1 inch 2.5cm
Light: 4inch 10cm
Moderate: 6inch 15cm
Heavy: Per Pad Saturated within 1hr.
Lochia Rubra: 3-4 days postpartum Dark bright red/ Menstrual odor/ Decreasing
Lochia Serosa: Up to 14th day postpartum pink, old blood, decrease amount
Lochia Alba: Up to 6 weeks postpartum White yellow creamy/light
Phases associated with the Mothering Role:
Rubin (1975) described three distinct phases that are associated with the woman’s assuming the mothering role. She labeled these phases:
“Taking-hold,” (2nd and 3rd day) and
“Letting-go” (2-6 weeks postpartum)
“Taking-in,” her birth experience in the first day or two after birth.
“Taking -hold,” Mom assumes care for herself and her infant. signs of bonding
“Letting-go,” Starts to focus on issues directly with herself and her newborn
DVT Deep Vein Thrombosis
Common during pregnancy
S & S: Depend on size
Unilateral Leg Pain
Positive Homan’s Sign
Calf Tenderness / Warm / Inflamed
Swelling / Maybe asymptomatic 50%
Pedal Pulse at +2
Developmental of Collateral Circulation
Degree of Vessel Occlusion
• Medications/labs for meds
ENOXAPARIN
LABS:
– D-dimer
– Basic Chemistry test
– PT and PTT
Thrombophlebitis = Thrombus + Inflammation
Describe inflammation
Typically occurs in CALFS
Risk during postpartum
Thrombosis
Superficial Venous Thrombosis
Deep Venous Thrombosis
Pulmonary Embolism Med: Warfarin/Heparin
Maintain antidotes on bedside (e.g., protamine sulfate for Heparin, Vitamin K for warfarin) to promptly treat drug overdose.
• Treatments
Collaborative management
Specific diagnostic procedures (e.g., venography and real-time and color Doppler ultrasound)
Avoid massage when DVT is suspected
When you sit, elevate your legs and do not cross them.
Drink plenty of fluids (10–12 8-ounce glasses) to prevent dehydration.
Avoid sitting in one position or standing for a prolonged period of time.
• Interventions
Avoid sitting in one position or standing for a prolonged period of time
Early ambulation is important; If ambulation is not possible, perform active and passive leg exercises. do not place pillows under your knees
Postpartum Psychosocial (PPD/Psychosis, Blues)
• Medications/contraindications/interactions, interventions, etc.
Postpartum Depression PPD
10% to 20% of postpartum women progress beyond the baby blues into postpartum depression (PPD), Occurs within 6 months postpartum.
S & S: Symptoms of PPD include
· depressed mood or decreased interest/pleasure in previously enjoyable activities,
· insomnia or hypersomnia,
· lack of appetite or weight loss,
· restlessness, anxiety,
– inability to cope, and feelings of hopelessness
N.I
Risk factors should begin with the first prenatal visit.
Cognitive behavioral therapy (CBT) and interpersonal psychotherapy (IPT) have been shown to be beneficial in treating perinatal depression. CBT is an action-oriented approach that treats maladaptive thinking as the cause of pathological behavior and “negative” emotions.
Exercise has been shown to increase levels of neurotransmitters (Dopamine) that communicate with brain cells to increase feelings of euphoria.
Medication for PPD:
SSRIs “lopran” suffix Anxiety/Depression
SNRIs “faxine” suffix Anxiety/Depression
TCAs/heterocyclics “pramine” “ptyline” suffix Anxiety/Depression
Mood stabilizer Lithium Bipolar/Postpartum psychosis
Postpartum Psychosocial (PPD/Psychosis/ Blues)
• Medications/contraindications/interactions, interventions, etc.
· Rare but severe form of mental illness.
· Affects not only the new mother but the entire family
· Greatest risk in those with pre-existing psychosis
· Behavioral cues that signal postpartum psychosis
· Collaborative management. Cognitive behavioral therapy (CBT) and interpersonal psychotherapy (IPT)
*IMPORTANT: Postpartum Psychosis may present with PPD symptoms; However, the distinguishing signs of Psychosis are Hallucinations, delusions, agitation, confusion, disorientation, sleep disturbances, suicidal and homicidal thoughts, and, loss of touch reality.
This condition may also resemble a sudden maniac attack. Mothers who are in a maniac state, require constant supervision when caring for the infant; they are frequently too preoccupied to tend to their infant’s needs.
N.I: Examples of bonding-oriented nursing care include rooming-in, decreasing sensory stimuli so that the family can focus on one another, and limiting visitors (if the patient desires).
Postpartum Blues:
· Common emotional response of periods of happiness followed by periods of tearfulness
· Self-limiting and resolve by 10 days postpartum.
· Signs & Symptoms:
· – Tearfulness, Mood swings, anxiety, fatigue, sadness, insomnia, forgetfulness and con fusion.
· Alleviating factors
Postpartum Hemorrhage:
Is a blood loss greater than 500 mL after a vaginal birth 1gr and, 1,000 mL (2gr) or more after a cesarean birth.
Is a serious condition.
Early Postpartum Hemorrhage: An early (primary) PPH occurs within the first 24 hours after childbirth.
Late Postpartum Hemorrhage: A late (secondary) PPH occurs from 24 hours to 12 weeks after childbirth.
When bleeding is associated with uterine atony or retained placental fragments, the blood is dark red with clots and the uterus is soft and boggy.
When the bleeding is associated with lacerations from the perineum, cervix or vagina, the blood is bright red, often without clots, and the uterus is firmly contracted.
MEDICATION:
Methylergonovine (Methergine) Contraindicated for HTN
oxytocin (Pitocin)
Carboprost tromethamine (Hemabate) Contraindicated in Asthma, Cardiac, hepatic, renal pts
Misoprostol (Cytotec)
