NCM 101 Lecture Notes FINALS Handout 8 _____________________ THE POSTPARTUM PERIOD:

Begins with the delivery of the placenta and ends when all of the bodily systems return to their pre-pregnant state The period of involution approximately encompasses 6 weeks

MUST KNOWS:
The vagina remains smooth walled for 3-4 weeks before rugae start to reappear. The first menstrual cycle postpartum is usually ANOVULATORY Menses may resume in 4-6 weeks if the mother is not breastfeeding Levels of HCG and HPL are almost negligible by 24 hours

Puerperium 5th stage of labor, 1st 6 weeks post-partum Characterize by involution Involution - return to the normal stage of reproductive organ after pregnancy Return to Normal Healing: Physiologic Changes and Systemic Changes Cardiovascular System o plasma volume o sudden in blood volume o elevated WBCs up to 30, 000 mm3 o hyperfibrinogenemia o orthostatic hypertension can be possible o early ambulation prevents thrombos formation steps in ambulation Flat Semifowlers Fowlers with dangling Walk with assist Genital Tract o Fundus goes down 1 finger breadth a day 10th day non palpable behind the symphysis pubis Subinvolution delayed healing of uterus containing quarters or clots of blood may lead to puerperal sepsis Management : D&C o After Pains After birth pains Multiparous breastfeeding most common to develop Position = prone Cold compress Mefenamic acid o Lochia Components Blood Decidua WBC Microorganisms 3 types Rubra 1 3 days, musty, moderate amount Serosa 4 10th day, pink or brown Alba 10 21th day, crme white, amount Urinary Tract o Urinary Frequency due to urinary retention with overflow o Dysuria Damage to the bladder Urine collection for culture and sensitivity Stimulate navel to urinate

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Ms. April Anne D. Balanon

NCM 101 Lecture Notes FINALS Handout 8 _____________________

Palpate bladder Listening to Running water Pull pubic hair - stimulate cremasteric reflex

Colon o Constipation Due to NPO Bearing down may cause pain Perenium o Pain relieved by sims position o Cold compress 1st 24 hours if there is pain at episiorraphy followed by warm compress EMOTIONAL SUPPORT 1. Taking phase 1st 3 days dependent phase passive, cant make decision tells about childbirth experience focus on: Hygiene 2. Taking Hold 4 7th day dependent to independent phase active, decides actively focus: care of newborn health teaching : Family planning 3. Letting Go Interdependent phase Redefines goals, new roles as parents May extend till the child grows Post Partum Blues 4th 5th days overwhelming feeling of depression, inability of sleep and lack of appetite 50 80% incidence rate cause by sudden hormaonal change progesterone suddenly decreases allow crying: therapeutic may lead to postpartum psychosis/ depression

POSTPARTUM BLUES 1-10 days after ONSET birth SYMPTOMS Sadness, crying spells INCIDENCE 70% of all births Support and THERAPY empathy ETIOLOGY Hormonal changes, stress

POSTPARTUM DEPRESSION 1-12 months after birth Anxiety, feeling of loss, sadness 10% of all births Counseling and drug therapy Hx of previous depression, hormonal responses and changes, lack of social support systems Refer to counseling

POSTPRTUM PSYCHOSIS Within the first month after birth Delusions and hallucinations, signs of harming infant and self 1-2% of all births Psychotherapy and drug therapy Possible activation of previous mental illness, hormonal changes, family history of bipolar disorders

NURSING ROLE

Offering compassion and understanding

Refer to counseling and safeguard mother from injury to self and to the newborn

Postpartal Complications Hemorrhage bleeding within 24 hours postpartum

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Ms. April Anne D. Balanon

NCM 101 Lecture Notes FINALS Handout 8 _____________________

Early Pospartal Hemorrhage 1. Uterine Atony boggy fundus profuse bleeding interventions o massage the uterus o cold compress o modified trendelenburg o fast drip IV o breastfeeding to release oxytocin 2. Laceration well contracted uterus with profuse bleeding assess perenium for laceration degrees of laceration o 1st degree vaginal skin and mucus membrane o 2nd degree 1st degree + muscles o 3rd degree 2nd degree + external sphincter of rectum o 4th degree 3rd degree + mucus membrane of rectum 3. Hematoma bluish discoloration of subQ tissues of vagina or perenium candidates o delivery of very large babies o pudendal block o excessive manipulation due to excessive IE intervention o cold compress 10 20 min then allow 30 minutes rest period for 24 h 4. DIC disseminated intravascular coagulation Consumption of pregnancy (otherterm) Failure to coagulate Bleeding in the eyes, ears, nose Oozing blood Seen in cases with o Abruptio placenta o Still birth / IUFD Management o Blood transfusion of cryoprecipitate or fresh frozen plasma o hysterectomy Late Postpartum Hemorrhage Retained placental fragments manual extraction of fragments is done uterine massage D&C except for cases of o Placenta Acreta umusual attachment of the placenta to the myometrium o Placenta Increta deeper attachment of placemat to the myometrium o Placenta Percreta invasion of placenta to the perimetrium Candidates of these disorders are Grand multiparous Post CS All these requires hysterectomy Infection Sources o Endogenous from normal flora of the body o Exogenous from the health care team Most common Anaerobic Streptococci Management o Supportive care

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Ms. April Anne D. Balanon

NCM 101 Lecture Notes FINALS Handout 8 _____________________

o o o o Fluid intake TSB if there is fever/ cold compress + paracetamol may also be given Analgesics Given on time to achieve maximum effect Culture and sensitivity

Perenial Infection Same s/ sx with infection 2 3 stitches are dislodges with purulent drainage Tx resuturing Endometritis Inflammation of the endometrium Gen s/sx of infection + abdominal tenderness Management o High fowlers facilitates drainage & localize infection o Administer oxytocin

ANATOMIC AND PHYSIOLOGIC ADAPTATION OF THE NEW BORN FETUS NEWBORN Fluid filled Air filled RESPIRATORY High pressure system Low pressure system SYSTEM
causes the blood to be shunted from the lungs though the ductus arteriosus to the rest of the body encourages blood flow through the lungs for gas exchange Increased 02 content of the blood in the lungs contributes to the closing of the ductus arteriosus Lungs Pressure in the left atrium is greater than the right. This causes the foramen ovale to close

SITE OF GAS EXCHANGE CIRCULATION THROUGH THE HEART

Placenta Pressure in the right atrium is greater in the left Encourages blood flow through the foramen ovale Ductus venosus bypassed Maternal liver performs filtering functions Body temperature maintained by maternal body temperature and the warmth of the intrauterine environment

HEPATIC AND PORTAL CIRCULATION THERMOREGULATION

Ductus venosus closes and becomes a ligament hepatic and portal circulation begins Fixed posture Brown fat- which is a specialized form of heat producing tissue found only in fetuses and in newborns

ASSESSMENT OF THE HEAD:

Bregma: =DIAMOND SHAPED =closes at 12-18 months of age Lambda: begins to close at about 2 months of age Bulging fontanels may indicate increased ICP Sunken fontanels may indicate _____________________ _________________________ results from pressure of the presenting part against the cervix which delays venous return resulting to accumulation of fluids within the scalp ( disappears without treatment in 3-4 days )

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Ms. April Anne D. Balanon

NCM 101 Lecture Notes FINALS Handout 8 _____________________

Forceps delivery and too much pressure against the pelvis may lead to rupture of several capillaries of the periosteum of the fetal skull resulting to accumulation of blood between the skull bone and the periosteum resulting to this finding: ________________________________( resolves within 3-6 weeks after birth without treatment )

ASSESSMENT OF THE EARS:

The level of the top part of the ear should be in line with the outer cantus of the eye Children with Ears below this line are known to have downs syndrome

ASSESSMENT OF THE EYES

True eye color begins to show at 3-4 months after birth Tears appear after 3-4 months

ASSESSMENT OF THE MOUTH

Rooting, sucking, and extrusion reflex should be present at birth New born babies have scanty saliva because of immature salivary glands _________________________ Teeth found in newborns. Should be uprooted to prevent aspiration _________________________ Small white cysts seen at the palate which are accumulation of epithelial cells. These disappear within 2 weeks

ASSESSMENT OF THE CHEST

Chest retractions= RDS Bulging of the chest= pneumothorax

ASSESSMENT OF THE BREAST:

________________________- Is a thin watery fluid secreted by the newborns nipple which disappears within the first week of life. It is caused by the influence of maternal hormones.

ASSESSMENT OF THE SKIN:

_________________________: irregular discoloration of the skin resulting from vasoconstriction, lack of fat and hypoxia Newborns do not sweat because of immature sweat glands. Sweating will begin after a month _________________________: white cheese like substances in skin creases which are accumulation of old cutaneous cells and secretions of the sebaceous glands while in the utero. Sebaceous glands function intrautero because of/ in response to hormones of the mother. _________________________: clogged and distended sebaceous glands seen on the newborns face, particularly on the nose. These disappear without treatment within 2-4 weeks after birth when the glands mature and drain _________________________: fine downy hairs found on the infants shoulders, back, cheek, forehead, and upper arm _________________________: bluish discoloration of the lower back and buttocks seen mostly in children of Asian and African ancestry _________________________: a harmless rash found in many newborns, results from a reaction to clothes and sheets. Subsides in 2 weeks without treatment _________________________: bluish discoloration of the skin _________________________: bluish discoloration of the hands and feet due to poor peripheral circulation _________________________: turning pale of the upper half of the body while the lower portion develops a deep red color when the infant is put on side lying

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Ms. April Anne D. Balanon