Postpartum Period Lecture 9 Chapter 20
Lecture 7PostpartumCh 20, 21, & 23
Lynne Rhodes, MSN, APRN, FNP-C
POSTPARTUM PERIOD
Think Safety!!
What can go wrong?
What is normal/abnormal?
What will be my first action if abnormal findings occur?
Reproductive System: Uterus
Involution: return of uterus to a nonpregnant state following
birth
Fundus descends 1 to 2 cm every 24 hours
2 weeks after childbirth, uterus lies in true pelvis
Subinvolution: failure of uterus to return to nonpregnant
state
Common causes are retained placental fragments and infection
Involution
The fundus will be at about 1 cm or fingerbreadth above the
umbilicus for the 1st 12-24 hours after delivery, then begins a
slow descent into the pelvis. Most important in checking the
fundus
IT SHOULD NEVER MOVE UPWARDS OR DEVIATE FROM THE MIDLINE!!
Reproductive System: Cervix
Soft immediately after birth
Within 2 to 3 postpartum days it has shortened, become firm, and
regained form
Ectocervix appears bruised and has small lacerations
Optimal conditions to develop infection
Cervical os, dilated to 10 cm during labor, closes gradually
KAPLAN HINT: If patient has signs/symptoms of postpartum
infection, what should the nurse do?
Reproductive System: Vagina
Vagina gradually returns to prepregnancy size by 6 to 10 weeks
after childbirth
Pelvic muscular support (Kegel exercises)
Thickening of vaginal mucosa occurs with return of ovarian
function
Dryness and coital discomfort, dyspareunia, may persist until
return of ovarian function
Introitus is erythematous and edematous
Episiotomies heal within 2 to 3 weeks
Hemorrhoids and anal varicosities are common and decrease within
6 weeks of childbirth
Internal hemorrhoids may evert while woman is pushing during
birth
Cardiovascular System
Blood volume
Blood volume increase eliminated within first 2 weeks after
birth, with return to nonpregnancy values by 6 months
postpartum
Readjustments in maternal vasculature after childbirth dramatic
and rapid. Pulse may decrease to 50 (which could identify shivering
in patient).
Cardiovascular System
Cardiac output
Remains increased for 48 hours after birth
Decreases by 30% by 2 weeks postpartum
Stroke volume, cardiac output, end-diastolic volume, and
systemic vascular resistance remain elevated for 12 weeks
postpartum
Left ventricular volume and cardiac output remain elevated for 1
year postpartum
Hematologic system
Blood components
Hgb/Hct rise due to sudden decrease in plasma volume, UNLESS
patient has excessive blood loss
White blood cell count is elevated (making it difficult to use
WBC to determine infection
Coagulation factors elevated, increasing the risk for
thromboembolism.
Varicosities
Regress rapidly immediately after childbirth
Total or nearly total regression of varicosities is expected
after childbirth
Endocrine System
Placental hormones
Expulsion of placenta results in dramatic decreases of
placental-produced hormones
Decreases in chorionic somatomammotropin (hCS), estrogens,
cortisol, and placental enzyme insulinase reverse effects of
pregnancy
Estrogen and progesterone levels drop markedly
Urinary System
Diuresis occurs; woman excretes up to 3000ml/day of urine.
Bladder distention and incomplete emptying are common.
Persistent dilatation of ureter and renal pelvis increase risk
for UTI.
Urine glucose, creatinine, and BUN levels are normal after 7
days.
Gastrointestinal System
Appetite
Most new mothers very hungry after recovery from analgesia,
anesthesia, and fatigue
Bowel evacuation
Excess analgesia and anesthesia may decrease peristalsis.
Spontaneous bowel evacuation may not occur for 2 to 3 days after
childbirth
Musculoskeletal System
Reversal of pregnancy adaptations
Pelvis muscles regain tone in 3 to 6 weeks.
Abdominal muscles regain tone in 6 weeks unless diastasis recti
(seperation of rectus abdominis muscles) occur.
New mother may notice permanent increase in shoe size
Neurologic System
Pregnancy-induced neurologic discomforts abate after birth
Headache requires careful assessment
Postpartum headaches may be caused by gestational hypertension,
stress, and leakage of cerebrospinal fluid into the extradural
space during placement of needle for epidural or spinal
anesthesia
Integumentary System
Chloasma of pregnancy usually disappears at end of pregnancy
Hyperpigmentation of areolae and linea nigra may not regress
completely after childbirth
Some women will have permanent darker pigmentation of those
areas
Stretch marks on breasts, abdomen, and thighs may fade but not
disappear
Integumentary System
Vascular abnormalities, spider angiomas, palmar erythema, and
epulis regress with rapid decline in estrogens
Spider nevi persist indefinitely for some
Hair growth slows during postpartum period
Abundance of fine hair during pregnancy usually disappears after
birth
Coarse or bristly hair that appears during pregnancy usually
remains
Integumentary System
Profuse diaphoresis in immediate postpartum period is most
noticeable change in integumentary system
Mostly occurs at night
Body is losing excess tissue fluid accumulated during
pregnancy
Occurs due to loss of the increased blood volume of
pregnancy
Immune System
No significant changes in maternal immune system occur during
postpartum period
Mothers need for rubella vaccination or for Rho (D) immune
globulin for prevention of Rh isoimmunization is determined
REMEMBER:
RhoGam is given to mothers who are Rh-negative when fetus is
Rh-positive and has a negative direct Coombs test. If the mother
has a positive Coombs test, there is no need to give RhoGAM, but if
the Coombs is negative RhoGAM must be given within 72 hours of
delivery
The MMR vaccine is given to mothers who are not rubella-immune.
THEY SHOULD BE INFORMED NOT TO GET PREGNANT FOR AT LEAST 3 MONTHS
AFTER THE VACCINE!
Chapter 21
Nursing Care during theFourth Trimester
Fourth Stage of Labor
First 1 to 2 hours after birth
Breastfeeding is recommended to begin
Postanesthesia recovery
Regardless of obstetric status, no woman should be discharged
from recovery area until completely recovered from anesthesia.
When the mother feels ready to stand, the nurse should always
stay with her the first time up!!
Vital Signs/Lab
Vitals
1st Hour q15min
2nd Hour q 30 min
Q hour thereafter
Once discharged q 4-8hrs
Lab
H/H to assess blood loss
Urinalysis
Rubella and Rh
Vital SignDescriptionTemperatureMay rise to 100.4 due to
dehydrating effects of labor. Any higher elevation may be due to
infection and must be reportedPulseMay decrease to 50 (normal
puerperal bradycardia). Pulse >100 may indicate excessive blood
loss or infection.Blood PressureShould be normal. Suspect
hypovolemia if it decreases, preeclampsia if it
increases.RespirationsRarely change. If respirations increase
significantly, suspect pulmonary embolism, uterine atony, or
hemorrhage.
For slight elevation in body temperature, increase fluid
intake.
Lowered heart rate may lead to shivering.
Pain is usually the priority nursing diagnosis if no excessive
bleeding.
B = Breasts
U = Uterus (Fundus)
B = Bladder
B = Bowel
L = Lochia
E = Episiotomy
H = Homans Sign
E = Emotions
Postpartum Assessment
BREASTS
Engorgement
48-72 hrs after delivery
Inspect for nipple inversion, cracks, blisters, fissures and
tenderness
Breasts
Non-lactating women
Breast binding with an Ace bandage
Ice packs for 30-60 min. Off 1 hour
Support bra not loose fitting.
No Breast stimulation do NOT
express milk!
Cold cabbage leaves
leave on until wilted
Tylenol
Breasts
Lactating women
Teach proper technique, holding infant, latch on, when to switch
breasts. Important to help prevent engorgement and mastitis.
Lanolin after each feeding; no need to cleanse prior to
feeding
Support and encouragement, breastfeeding is learned skill for
mother and infant
Breast milk bluish in color and thin; reassure this is
normal
Report pain, swelling, redness immediately, especially if only
one breast affected!!
UTERINE INVOLUTION
Monitor by assessing:
Uterine size and location
Uterine tone
boggy vs. firm
Administering Pitocin after delivery of placenta stimulates
uterine involution.
Usually will be 20-40 units Pitocin in 1 liter fluid.
Afterpains or afterbirth pains
Caused by contractions of the uterus as it goes through
involution.
Increased by breastfeeding and/or Pitocin infusion.
Treatment give pain medication.
Fundal Massage
#1 Nursing Action for postpartum bleeding!!!!!
UTERINE SUBINVOLUTION
Failure of uterus to return to non-pregnant state
Most common causes
Infection
Retained placental fragments
Prevention of Excessive Bleeding
Uterine Atony- failure of muscles to contract firmly. It is the
most frequent cause of excessive bleeding
Nurse must!!!
Maintain uterine tone MASSAGE!!!!
Prevent OR correct bladder distention
BOWEL
Usually become hungry 1-2 hrs after delivery
Bowel movements occur 2-3 days pp
Narcotics will depress bowel motility
Stool softeners routinely given pp (Dulcolax/ Colace)
Bowel
May have hemorrhoids
Ice pack application immediately after delivery and for first 24
hours
Hemorrhoids common pp especially in prolonged labor or with
prolonged pushing
witch hazel and topical anesthetics routinely ordered pp
BLADDER
Effects of anesthesia may last several hours.
need staff assistance when ambulating to bathroom for first time
or for first several times in order to prevent falls. STAY WITH
PATIENT FIRST TIME OUT OF BED!!
Make sure you educate your patient to call nurse when needing to
void.
Remember . . .
Client should void within 4 hours of delivery. Monitor client
closely for urine retention. Suspect retention if voiding is
frequent and 30 min
Preeclampsia
Asian or Hispanic ethnicity
Operative birth
Retained placental fragments
Early Post-Partal Hemorrhage
Other causes of P.P. hemorrhage:
Lacerations
Retained placental fragments
Hemotomas
Coagulation disorders
Late Post-Partal Hemorrhage
After the first postpartum day, the most common cause of uterine
atony is retained placental fragments.
The nurse must check for the presence of fragments in lochia
tissue.
Hemorrhage
Blood pressure and pulse may NOT change until significant blood
loss has occurred d/t extra blood volume of pregnancy they are a
late sign of shock in the postpartum woman!!
exception is preeclamptic women; they do not have hypervolemia
of pregnancy
Post-Partum Hemorrhage
Management Options
Massage fundus !!!!!!!!!!!!!
Check for bladder distention/voiding
Quantify blood loss
Watch vital signs
Notify provider
Hypovolemic Shock
Skin cool and clammy
Pulse rate increases
BP declines
Skin ashen or grayish
Women acts anxious
What are your nursing interventions?
Nursing Interventions for Hypovolemic Shock
MASSAGE THE FUNDUS!!!!
Notify physician
8/10L O2 via face mask
Tilt pt. to left side and raise legs.
IV fluids
Blood products if ordered
Monitor VS
Insert foley catheter
Administer emergency drugs if ordered
Prepare for possible surgery
Document! Document! Document!
EPISIOTOMY
To assess, have patient lay on her side, flexing her upper leg
toward the hip or place in lithotomy position
Signs of infection-pain, redness, warmth, swelling, discharge or
loss of approximation
Episiotomy will heal within 2-3 wks
Pericare
Peri-bottle, pads, Dermoplast, Tucks to keep at bedside
Use peri-bottle to cleanse perineum after each urination and
bowel movement
daily washing with warm water and mild soap
wipe front to back
change peri-pad frequently
good hand washing
Pericare
Warm therapies after first 24 hours
Warm Sitz baths will aide in easing episiotomy discomfort
Heat lamp for 20 minutes 2-3 times a day
Teach Kegels
Perineum
Inspect episiotomy for hematoma
extremely painful
unable to void
mass palpated or observed
HOMANS SIGN
DVT assessment and prevention Homans sign, redness, pain
Also assess:
Extremities:
Assess for sensation and mobility when epidural or spinal
anesthesia
Should be able to move toes and lift buttocks off bed within 2-4
hours after discontinuation of anesthesia
Dependent edema is common
Assess for edema: pitting vs. non-pitting
EMOTIONS
Attachment
Process by which parents come to love and accept a child and a
child loves and accepts a parent
Bonding
Sensitive time immediately after birth when parents must have
close contact with their infant in order for later development to
be normal-Klaus & Kennell-1976
These terms are used interchangeably
3 Phases of Psychological Adaptation
Taking in: dependency behaviors for 24-48hrs.
Taking hold: less focus on physical discomforts, beginning
confidence with infant care taking.
Letting go: total separation of NB from self; confident in care
taking activities of self and NB.
If adaption does not occur, why? Are mother and infant
safe???
Care Management: Physical Needs
Comfort usually #1
Nonpharmacologic interventions
Pharmacologic interventions
Rest, fatigue, ambulation, and exercise
Cultural Awareness nurses role is to support unless the
activity, food, etc. is harmful.
Discharge Teaching
Teaching for self-care: signs of complications
Sexual activity/contraception
KAPLAN HINT: Remember ovulation will occur before first
period!!
Prescribed medications
Routine mother and baby checkups
Dealing with activities of daily life at home
Dealing with visitors
Discharge Teaching
Follow-up after discharge
Home visits
Telephone follow-up
Warm lines
Support groups
Referral to community resources
Remember . . .
Client and family teaching is a common subject of NCLEX-RN
questions. Remember that when teaching, the first step is to assess
the clients level of knowledge and to identify their readiness to
learn. Client teaching regarding lochia changes, perineal care,
breastfeeding, and sore nipples are subjects that are commonly
tested.
Chapter 23
Postpartum Complications
Postpartum Hemorrhage
Definition and incidence
PPH traditionally defined as loss of more than:
500 ml of blood after vaginal birth
1000 ml after cesarean birth
Cause of maternal morbidity and mortality
Life-threatening with little warning
Often unrecognized until profound symptoms
Postpartum Hemorrhage
Etiology and risk factors
Uterine atony
Marked hypotonia of uterus
Leading cause of PPH, complicating approximately 1 in 20
births
Lacerations of genital tract
Retained placenta
Nondherent retained placenta
Adherent retained placenta
Care Management
Assessment
Bleeding assessed for color and amount
Perineum inspected for signs of lacerations or hematomas to
determine source of bleeding
Vital signs may not be reliable indicators because of postpartum
adaptations
Measurements during first 2 hours may identify trends related to
blood loss (tachycardia, tachypnea, decreasing bp)
Laboratory studies of hemoglobin and hematocrit levels
Most objective, least invasive assessment of adequate organ
perfusion and oxygenation is UO of > or = 30ml/hour!!!
Care Management
Plan of care and implementation
Medical management
Hypotonic uterus
Bleeding with a contracted uterus
Uterine inversion
Subinvolution
Herbal remedies
Care Management
Plan of care and implementation
Nursing interventions
Providing explanations about interventions and need to act
quickly
Instructions in increasing dietary iron, protein intake, and
iron supplementation
May need assistance with infant care and household activities
until strength regained
Hemorrhagic (Hypovolemic) Shock
Medical management
Nursing interventions
Fluid or blood replacement therapy
Coagulopathies
Idiopathic thrombocytopenic purpura (ITP)
von Willebrand diseasetype of hemophilia
Disseminated intravascular coagulation (DIC)
Pathologic clotting
Correction of underlying cause
Removal of fetus
Treatment for infection
Preeclampsia or eclampsia
Removal of placental abruption
Thromboembolic Disease (DVT)
Results from blood clot caused by inflammation or partial
obstruction of vessel
Incidence and etiology
Venous stasis
Hypercoagulation
Clinical manifestations
+Homans sign, redness, swelling, pain
Medical management
Nursing interventions
PREVENTION:
Use of TED hose or ICD device
Early ambulation
Postpartum Infections
Puerperal sepsis: any infection of genital canal within 28 days
after abortion or birth
Most common infecting agents are numerous streptococcal and
anaerobic organisms
Endometritis
Urinary tract infections
Mastitis
C/section incision red, edematous, tender, purulent drainage
Management notify MD
Prevention HANDWASHING!!
Sequelae of Childbirth Trauma
Disorders of uterus and vagina related to pelvic relaxation and
urinary incontinence, are often result of childbearing
Uterine displacement and prolapse
Posterior displacement, or retroversion
Retroflexion and anteflexion
Prolapse a more serious displacement
Cervix and body of uterus protrude through vagina and vagina is
inverted
Sequelae of Childbirth Trauma
Cystocele and rectocele
Cystocele: protrusion of bladder downward into vagina when
support structures in vesicovaginal septum are injured
Rectocele is herniation of anterior rectal wall through relaxed
or ruptured vaginal fascia and rectovaginal septum
Urinary incontinence
Sequelae of Childbirth Trauma
Genital fistulas
May result from congenital anomaly, gynecologic surgery,
obstetric trauma, cancer, radiation therapy, gynecologic trauma, or
infection
Vesicovaginal: between bladder and genital tract
Urethrovaginal: between urethra and vagina
Rectovaginal: between rectum or sigmoid colon and vagina
Postpartum Psychologic Complications
Mental health disorders in postpartum period have implications
for mother, newborn, and entire family
Interfere with attachment to newborn and family integration
May threaten safety and well-being of mother, newborn, and other
children
Postpartum Psychologic Complications
Postpartum depression without psychotic features
PPD: an intense and pervasive sadness with severe and labile
mood swings
Disappointment with outcome of pregnancy
Treatment options
Antidepressants, anxiolytic agents, and electroconvulsive
therapy
Psychotherapy focuses fears and concerns of new responsibilities
and roles, and monitoring for suicidal or homicidal thoughts
KAPLAN HINT: Encourage mother to talk and provide support.
Postpartum Psychologic Complications
Postpartum depression with psychotic features
Postpartum psychosis: syndrome characterized by depression,
delusions, and thoughts of harming either infant or herself
SAFETY!!
Psychiatric emergency, and may require psychiatric
hospitalization
Antipsychotics and mood stabilizers such as lithium are
treatments of choice
Loss and Grief
Losses of what was hoped for, dreamed about, and/or planned
Any perception of loss of control during the birthing
experience
Birth of a child with handicap
Maternal death
Fetal or neonatal death
Loss and Grief
Conceptual model of parental grief
Acute distress
Intense grief
Reorganization
Anticipatory grief
Loss and Grief
Plan of care and implementation
Communicating and care techniques
Actualize the loss
Provide time to grieve
Interpret normal feelings
Allow for individual differences
Cultural and spiritual needs of parents
Physical comfort
Loss and Grief
Plan of care and implementation
Options for parents
Seeing and holding
Bathing and dressing
Privacy
Visitations: other family members or friends
Religious rituals/funeral arrangements
Special memories
Pictures
Maternal Death
Rare for woman to die in childbirth
Families are at risk for developing complicated bereavement and
altered parenting of surviving baby and other children in
family
Referral to social services can help combat potential problems
before they develop
