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Postpartum Physiology, What's Normal?

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Postpartum Physiology, What's Normal? 3/21/2018 Starting at her head “Are you Postpartum Physiology, experiencing a “Any visual headache?” changes… such what’s normal? as blurry vision/ seeing spots?” Let’s go over a head to toe maternal “I am going to be monitoring your postpartum assessment together temperature. When you are at home if you have an She may have temperature of 100.4 questions about or greater you need to contact your her skin, the health care provider” possible changes Neurologic Changes/Conditions Postdural puncture headache (spinal headache) • Headache • Leaking of cerebrospinal fluid from the site of a – Most common neurologic symptom puncture of the dura mater –Can occur from • Most common when dura is accidently punctured during epidural placement • Fluid shifts • Assuming an upright position triggers a change in • Stress volume of CSF and leaking • Spinal headache – Intensifies headache – • Fluid and Electrolyte imbalance Auditory problems – Visual problems • Preeclampsia • Signs and symptoms begin within 2 days and may persist for days or weeks Postdural puncture headache Temperature • Nursing Care If in the first 10 days postpartum (excluding – Administration of oral analgesics and methylxanthines the first 24 hours post delivery) if mom has: (caffeine or theophylline) – Remain laying as position change precipitates the fluid • Oral temperature of >100.4 degrees Fahrenheit shift on two occasions that are 6 hours apart think – Epidural blood patch possible puerperal infection • 20 ml of the patient’s blood is injected slowly into the lumbar area of the epidural space. – Cardinal symptoms of postpartum infection include an • This creates a blood clot that patches the dura mater elevated temperature, tachycardia, and pain. • Most rapid and beneficial relief method 1 3/21/2018 Vital signs What is a puerperal infection? Normal Findings Deviations From Normal Findings with probable causes • An infection of the reproductive tract associated Temperature: Temperature: Slight increase in the first 24 hours to 38 degrees C (100.4 greater than 38 degrees C (100.4 degrees F) after 24 hours with childbirth, which may occur anytime up to degrees F) due to dehydration. Afebrile after 24 hours can be indicative of infection (mastitis, endometritis, urinary tract infection, other systemic infections) six weeks post delivery Pulse: Pulse: • Most common puerperal infection is Slight elevation in first hour after birth that gradually Rapid or increasing pulse rate can indicate hypovolemia declines over 48 hours. Puerperal bradycardia of 40-50 bpm endometritis is common • A mom may be discharged prior to symptoms of a Respirations: Respirations: Return to pre-pregnancy rate soon after birth Hypoventilation can be a result of an unusually high spinal puerperal infection becoming apparent, proper block or epidural medication after a cesarean section discharge teaching is necessary. About 84% of Blood Pressure : Blood Pressure: Slight transient return of approx. 5% increase over the first Hypotension can indicate hypovolemia (late sign), postpartum infections manifest after discharge few days to weeks after delivery. Orthostatic hypotension Hypertension can be caused by excessive use of may be a result of splenic engorgement after birth vasopressor or oxytocin. Gestational hypertension may from the hospital. continue for weeks after delivery, assess for corresponding signs of preeclampsia Integumentary Changes How often to complete a • Cholasma (mask of pregnancy) comprehensive maternal assessment? – Usually disappears in the postpartum woman. May persist in First Hour Second Hour First 12-24 Hours about 30% of women • Hyperpigmentation of areola and linea negra may not Every 15 Minutes Every 30 Minutes Every 4 hours completely regress • Striae gravidarum (stretch marks) on breast, abdomen, and • Follow your facility’s protocols thighs may fade but usually do not disappear completely • This is a guide, may need to be done more frequently • Spider angiomas and palmer erythema usually regresses • To promote maternal safety and optimal outcomes there rapidly due to decreased estrogen have not been clinical trials to state exactly how often to – Spider angiomas may persist indefinitely in some women assess during the postpartum period: guidelines state • Hair loss may occur as the rapid growth associated with what to assess but don’t states exactly how often pregnancy ends • Except temperature, 2008 ACOG and AAP state at least • Hair and nail strength return to pre-pregnancy states every 4 hours during the immediate postpartum period AWHONN Perinatal Nursing 2014 Maternal Blood Pressure Maternal Blood Pressure If there is a rise in blood pressure • Many women have a rise in blood pressure • Continue to closely observe blood pressure right after delivery readings. If the reading is 140/90 mm Hg on two or • This is a transient increase in both the systolic more occasion at least 6 hours apart (AWHON 2014) and diastolic • Or this patient is having headaches/visual changes • This will spontaneously return to the pre- the health care provider needs to be aware (AWHON 2014) pregnancy baseline over the next few days Be aware that preeclampsia can persist into or occur for the first time in postpartum 2 3/21/2018 Nursing Care • Orthostatic hypotension may happen in the first 48 hours post delivery – May be due to the decrease in intrapelvic pressure – She may feel dizziness right after moving to a standing position Maternal Blood Pressure • How should BP be taken? Let’s Discuss – See resources section under Hypertension for full hand out on how to properly measure a Cardiovascular blood pressure Changes Decreased Heart Rate Elevated Heart Rate • Bradycardia is common during the first 6-10 • Tachycardia needs to be evaluated, may be days after delivery due to: • The heart rate is 50-70 beats per minute – Blood loss possibly related to: – Temperature elevation – Decreased cardiac strain – Infection – Decreased blood volume following placental – Prolonged labor separation – Fear – Increased stroke volume – Pain 3 3/21/2018 Cardiovascular Changes Cardiovascular Changes • Immediately following birth, • This will create an increased stroke volume (the amount of blood pumped with one contraction) autotransfusion occurs which will increase the cardiac output • So the 500-700 mL per minute of blood flow that • Which is what? was going to the uteroplacental unit is now in just the maternal systemic venous circulation right after delivery • It means that the blood that was going through the placenta stops, creating more blood circulating in just the maternal system Cardiovascular Cardiac output • Changes in blood volume is dependent on 10-15 minutes post delivery – Blood loss during birth cardiac output is at the highest – Amount of extravascular fluid that is excreted One hour post • Average blood loss delivery cardiac – Vaginal deliveries 300-500mL output reaches pre labor value By 6-12 weeks – Cesarean section deliveries 500-000 mL postpartum the cardiac output Delivery reaches prepregnant levels Declines by 30% in the first 2 weeks Cardiovascular Peripartum Cardiomyopathy • Maternal Physiological changes that allow the Defined as: new mother to accommodate for changes in “a weakness of the heart muscle that by definition blood volume include: begins sometime during the final month of – Elimination of utero-placental circulation • Reduces vascular bed by 10-15% pregnancy through about five months after – Loss of placental endocrine function delivery, without any other known cause.” • Removes the stimulus for vasodilation • Dr. Lili Barouch, Assistant Professor of Medicine, Division – Mobilization of extravascular fluid of Cardiology, Johns Hopkins School of Medicine • Movement of fluid from extravascular spacing to vasculature happens by 3rd day postpartum 4 3/21/2018 Peripartum Cardiomyopathy Signs and Symptoms • Actual cause is unknown Present with signs and symptoms of pulmonary • May be associated with nutritional and edema immunologic mechanisms – Dyspnea- difficult or labored breathing • Higher Incidence in: – Cough – Older gravidas – Orthopnea- sensation of breathlessness in the – Multiparas recumbent position, relieved by sitting or standing. – African-Americans – Tachycardia – Multiple gestations – Occasional hemoptysis- coughing up blood or blood – Patients with preeclampsia tinged mucous Evaluation of Respiratory Changes Respirations • Should remain within the normal range of 12- 20 breaths per minute • Variations to this may be: – pain, fear, excitement, exertion • Immediate attention is needed if she also has shortness of breath, chest pain, anxiety, restlessness…. could be a pulmonary emboli Pulmonary Embolism Normal Respiratory Changes Most common signs: Most serious signs • Tachpnea (>20 • Sudden breaths/min) collapse/Syncope After delivery the reduction in the • Tachycardia (>100 • Cyanosis intra abdominal pressure allows for beats/min) • Hypotention increased expansion of the diaphragm. • Dyspnea-labored breathing, • Presyncope Mom feels like she can take that deep shortness of breath breath again! • Chest pain • Hemoptysis- coughing up of blood or bloody sputum • Abdominal pain 5 3/21/2018 Respiratory Respiratory • When you let your breath out there is remaining air in your lungs, this is called residual volume • This too will normalize for mom soon after the baby is delivered • Everyone take a deep breath in….. Let that breath out • The volume of air you just inhaled and exhaled is called tidal volume • Tidal volume normalizes for mom soon after birth •
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