Assessment and Care of the

Newly Delivered Mother

Normal Postpartum Changes Uterus

• Rapid contraction of the uterine muscle and arteries

– compresses blood vessels

– thrombi form

– endometrium undermines site, area heals

Normal Postpartum Changes Uterus

• Normal size decrease ~1 cm/day

• Weight from 1000g to ~50-100g

• Size affected by parity, multiple gestation, or bladder distension

• After-pains start to in frequency

LOCHIA Rubra Serosa Alba

Normal

Color

Red Pink, brown

tinged

Yellowish-

white

Normal

Duration

1-3 days 3-10 days 10-14 days,

Can be

longer

Normal

Discharge

Bloody w/

clots

Serosang.,

Fleshy odor

Mostly

musus, no

strong odor

Abnormal

Discharge

Foul smell;

many lg.

clots,

saturate pad

Foul smell,

quickly

saturate pad

Foul smell,

rubra or

serosa flow;

lasts > 4 wks

Factors Affecting Lochia

• Factors: – Uterine atony, retained placental fragments/membranes, activity, distended bladder

– Duration not affected by choice of feeding method or use of oral contraceptives

• Warning signs – Foul-smelling lochia, unusually heavy flow, large clots, rubra continues by PPD4, saturates > 1pad/hr

• Final sloughing at 7-14 days

Perineum

• Perineal lacerations – 1º skin & superficial structures

– 2º reaches into perineal muscle

– 3º extends into anal sphincter muscle

– 4º involves anterior rectal wall

Perineum

• Comfort measures: warm or cool baths, ice packs, witch hazel pads, anesthetic sprays, po analgesics

• Report unusual discomfort, pain, drainage

• Continue perineal hygiene

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Cervix, Vagina, & Pelvic Floor

• Cervix & lower uterine segment flaccid immediately PP

• Cervix – by 2-3 days has resumed its usual appearance but remains dilated 2-3 cm., 1 cm by end of 1st week – Cervical edema may last several months

Vagina

• Vagina & vaginal outlet may appear bruised early after delivery; caused by pelvic congestion, disappears quickly after birth

• Involutes by contraction – Walls become gradually thicker, rugae return by ~ 3 weeks

• Pelvic floor tone regained during first 6 wks PP

Return of Menses

• Menses – return varies – First menses usually occurs within 7-9 wks PP if non-nursing

– Great variation in menses return if BF due to depressed estrogen levels. Usually returns between 2-18 months

• First menstrual cycle is usually anovulatory, but 25% may ovulate before menstruation

• Mean return of ovulation – ~ 10 wks PP if non-nursing – ~ 17 wks PP if breastfeeding

Return of Ovulation

Family Planning

• Discuss family planning – Wait until bleeding stops & have seen provider for 6 week follow-up appt.

– Discuss with provider at 6 wk. checkup

Fertility Care Program, 322-4434 (Creighton Model)

• 99.5% effective in spacing pregnancy

• Can an infertile couple’s chance of conceiving by 20-80%

• Simple charting based on external exams

• Can be used to treat GYN conditions: – Infertility, menstrual cramps, PMS, ovarian cysts,

abnormal bleeding, PCOS, repetitive miscarriage, PP depression, hormonal abnormalities, chronic discharge, pelvic pain

Normal Postpartum Changes Bladder

• Extensive diuresis to excrete excess fluid (2-3 L)

• capacity, tone • Risk of over-distention and incomplete

emptying

• Leakage, urinary frequency common • Mild proteinuria (1+) may exist for 1-2

days in ~ half of women

Normal Postpartum Changes Bladder

• Spontaneous voiding should occur by 6-8 hours PP; enc. Frequent voiding

• If cath’d, remove no more than 800 cc at one time

• Stress incontinence common

• Encourage Kegel exercises

• Observe for s/s UTI

Hemodynamic/Hematologic

• Normal EBL up to 500 ml vaginal birth, up to 1000 ml cesarean birth

• By 3rd day PP plasma volume as fluid shifts from extracellular to intravascular

• Excess fluid by 2 wks PP by diuresis and diaphoresis

• Leukocytosis to 14-16,000 during labor (or higher): remains 2-3 days PP

Hemodynamic/Hematologic

• Cardiac output peaks immediately after birth (autotransfusion)

• Decreases to pre-labor by 1 hour, remains for 24 hours, then to normal levels by 2 weeks

• Clotting factors in preg. & early PP – Assess for thrombus formation

Gastrointestinal • Relaxin slows GI tract, delays passage of stool

• Incontinence 6x more common w/ 3 and 4° lacerations

• Prevent constipation - should have BM by 2-3 days PP

• Hemorrhoids common

GI System

• Encourage non-pharmacological methods (fiber, fluids, warm drinks in AM, walking, etc.)

• OTC stool softeners

• Hemorrhoid OTC preparations

• Use care w/suppositories if

3 or 4 lacerations

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Musculoskeletal • Skin

– diaphoresis – stretch marks, pigmentation chg – varicosities, spider veins

• Stretched muscles and ligaments return to former state – Diastasis separation 2-3 fingerwidths; lasts ~ 2 wks

• Edema decreases 1-3 days PP • Hormonal effects regress over time

Neurologic

• DTR’s remain normal

• Multiple sources of discomfort – Fatigue, afterpains, incisions, muscle aches, breast engorgement or sore nipples, headaches

• Sleep disturbances r/t hormones

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Endocrine • Thyroid - risk of thyroiditis

– May develop during first month PP, most likely in weeks 3-4.

• Followed by thyroid storm – Life threatening emergency, caused by excessive amounts of thyroid hormones

– S/S: fever, marked weakness, extreme restlessness w/wide emotional swings, confusion, psychosis, even coma

• Followed by hypothyroidism – Extreme lethargy, fatigue, weight loss or later wt. gain, goiter formation

Endocrine: Glucose Metabolism

• Levels change r/t absence of pregnancy hormones – Decreased insulin needs if diabetic – Gestational diabetics return to normal

– 6 wk 75 gm glucose screen to R/O Type 2 DM (fasting BG ok if no further pregnancies planned)

Initial Postpartum Assessment

• Vital signs – Vag birth – q. 15 min. x 4, q. 30 min. x 2, then 1 hour, then q. 12 hrs or more frequent if indicated

– C/birth – q. 15 min. in PAR; then q. 30 min. x 2; q. 1 hr x 4 or 10; q. 2 hr x6 (if duramorph); then q. 4 hrs until 24 hour post-op. After 24 hrs: QID

• Physical assessment • Emotional considerations

Vital Signs

• Temp should be normal. Call if temp for 2 days (> 100.4° F) – Incisions, IV site, breasts, S/S UTI

• Pulse remains normal or decreases slightly after birth

• BP normal – Assess patients w/ DBP for HTN – Orthostatic BP common – BP can be late sign of hemorrhage

Assessment: BUBBLE-HEAD

• B Breasts

• U Uterus

• B Bladder

• B Bowels

• L Lochia/lungs

• E Episiotomy/ lacerations

• H Homan’s sign

• E Edema

• A Affect

• D Discomfort

Monitoring of Incisions

• Assessment of incisions – REEDA scale (Redness, Edema, Ecchymosis, Discharge, Approximation)

• Healing – Stitches absorb

(10 days)

Interventions for Incisions

• Episiotomy (perineal) – Wash hands before and after pad change, ice pack 1st 24 hours, change pads frequently, peri bottle after voiding, wipe front to back, wash with soap & water daily, tub/sitz baths

– Stitches dissolve in about 10 days

– Healing generally takes 4-6 weeks - may take longer for “no pain” (type of epis, ability to heal, infections, etc.)

Incisions

• Abdominal – Wash with soap & water daily, rinse well; keep clean and dry, soft cloth to whisk away moisture, assess daily for healing, remove steri strips in 7-10 days

– Healing takes ~ 6 weeks

Cesarean Considerations

• Recovery from anesthesia

• Auscultate bowel sounds q. 4 hours

• Observe for bladder distension, adequate urinary output

• Auscultate lung sounds

• Ambulate early & often!

Pain Control

• Perineal pain – Ice, topical anesthetics, Tucks, whirlpool

• Oral medications

• Protective positioning, splinting (C/S)

Other Issues

• Restructuring patient education – teaching in antepartum period about self and baby care

– age of informed consumer

– intrapartum & PP notoriously poor retention of teaching. Need time to rest and “practice” what has been learned earlier.

PP Teaching

• PP women have transient deficits in cognition, particularlyin memory function, the first day after giving birth (Rana, Lindheimer, Hibbard, & Pliskin, 2005).

• Verbal instruction immediately after birth or first PP day will be poorly remembered

• Need appropriate written materials

• Priorities for most women in 1st 24 hrs PP are rest, time to touch, hold, and get to know their baby, and an opportunity to review and discuss their L&D

Other Issues

• Providing alternative support services – Postpartum follow-up clinic/phone calls

– Lactation services

– Support groups

– Early parenting education

Questions???